Society has historically not taken a benign view of genetic disease. The laws permitting sterilization of the mentally re tarded~ and those proscribing consanguineous marriages are but two examples. Indeed as far back as the 5th-10th centuries, B.C.E., consanguineous unions were outlawed (Leviticus XVIII, 6). Case law has traditionally tended toward the conservative. It is reactive rather than directive, exerting its influence only after an individual or group has sustained injury and brought suit. In contrast, state legislatures have not been (...) inhibited in enacting statutes. Many of their products can be characterized as hasty, unnecessary, ill-conceived, and based on the heart rather than the head. Moreover the lack of expert consultation sought has also been remarkable. One state legislature, for example, has advocated immunization for sickle cell anemia! Many others have enacted laws for the screening of inborn errors of metabolism, e.g., phenylketon uria, but have poorly defined the lines of responsibility to secure compliance. A spate of specific disease-related bills has emerged in the u.S. Congress, each seeking recognition and appropriations. Sickle cell anemia, hemophilia, Cooley's anemia and Tay-Sachs disease have been among the front-runners for support. Finally, in 1975, Congress has begun to examine an omnibus bill concerning all forms of genetic disease. The bill, termed the National Genetic Diseases Act is, however, still far from being enacted. (shrink)

The topic of professionalism has dominated the content of major academic medicine publications during the past decade and continues to do so. The message of this current wave of professionalism is that medical educators need to be more attentive to the moral sensibilities of trainees, to their interpersonal and affective dimensions, and to their social conscience, all to the end of skilled, humanistic physicians. Urgent calls to address professionalism from such groups as the Association of American Medical Colleges, the (...) American Board of Internal Medicine, and the Accreditation Council for Graduate Medical Education, among others. In fact, at the 2004 annual meeting of the AAMC six separate presentations addressed professionalism with such titles as "Evaluating Humanism and Professionalism," Professionalism: Expectation, Education, Evaluation," or "Toward Assessing Professional Behaviors of Medical Students through Peer Observations". Professionalism, then, has become part of the current academic medicine parlance, used by administrators, clinical faculty, residency programs, and professional organizations with an expectation of shared meanings and goals. All of these stakeholders focus on what has become a consistent list of attributes deemed to be the essence of professionalism, which usually include variations on altruism, duty, excellence, honor and integrity, accountability, and respect. In fact, most of the scholarly work to date has been listing, describing, decrying, and measuring/evaluating it. In this collection of essays, we don’t argue with these attributes. Instead, we ask questions of the discourse from which they arise, how the specialized language of academic medicine disciplines has defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label "professional" or "professionalism." This collection aims to be a critical text, one that questions the profession’s beliefs about the nature of its work and how such beliefs are enacted in medical education, particularly as they fuel the professionalism discourse. In addition, we will scrutinize how the discourse is enacted in both the formal and hidden curriculum, and in the larger medical environment. (shrink)

Loneliness in medicine is a serious problem not just for patients, for whom illness is intrinsically isolating, but also for physicians in the contemporary condition of medicine. We explore this problem by investigating the ideal physician-patient relationship, whose analogy with friendship has held enduring normative appeal. Drawing from Talbot Brewer and Nir Ben-Moshe, we argue that this appeal lies in a dynamic form of companionship incompatible with static models of friendship-like physician-patient relationships: a mutual refinement of embodied virtue (...) that draws both persons together. The ideal physician-patient relationship has a dialectical character that fosters each member's improvement of phenomenologically recognizing and embodying moral virtues. A key component of this dynamic is a commitment to the common goal of the patient's health, realized through joint interactivities and conversations over time. The physician's presence to the patient's suffering—understood best as an alienating phenomenological condition for the patient—orients and discloses possibilities for virtuous caregiving by structuring the meanings of the goals, conversations, and joint narrative constitutive of their relationship. Presence to suffering, paradoxically, is perhaps an important prerequisite for this dynamic partnership. These activities dialectically build an interpretive horizon of understanding through which moral goods and character refinement—in and for the other—may become revealed for both persons in their shared being-in-the-world. This analysis of suffering, mood, and revealing of (possible) moral goods has implications for addressing the modern problem of loneliness for patients and physicians, who are increasingly inhibited from building flourishing relationships with each other. (shrink)

Battle Hall Davies' brother Nick ran away from home when she was in high school. Now he has found her and she is going to stay with him for the summer before starting college. Battle discovers that neither she nor her brother is the person she thought they were.

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

In this chapter, we consider ethical and philosophical aspects of trust in the practice of medicine. We focus on trust within the patient-physician relationship, trust and professionalism, and trust in Western (allopathic) institutions of medicine and medical research. Philosophical approaches to trust contain important insights into medicine as an ethical and social practice. In what follows we explain several philosophical approaches and discuss their strengths and weaknesses in this context. We also highlight some relevant empirical work in (...) the section on trust in the institutions of medicine. It is hoped that the approaches discussed here can be extended to nursing and other topics in the philosophy of medicine. (shrink)

Intuition in medical and moral reasoning -- Moral intuitionism -- The place of Aristotelian phronesis in clinical reasoning -- Aristotle's practical syllogism: accounting for the individual through a theory of action and cognition -- Individual and statistical physiognomy: the art and science of making the invisible visible -- Clinical intuition versus statistical reasoning -- Contingency and correlation: the significance of modeling clinical reasoning on statistics -- Abduction: the intuitive support of clinical induction -- Conclusion: medical ethics beyond ontology.

It is surely obvious that medicine, like any other rational activity, must be based on evidence. The interest is in the details: how exactly are the general principles of the logic of evidence to be applied in medicine? Focussing on the development, and current claims of the ‘Evidence-Based Medicine’ movement, this article raises a number of difficulties with the rationales that have been supplied in particular for the ‘evidence hierarchy’ and for the very special role within that (...) hierarchy of randomized controlled trials (and meta-analyses of the results of randomized controlled trials). The point is not at all to question the application of a scientific approach to evidence in medicine, but, on the contrary, to indicate a number of areas where philosophers of science can contribute to a proper implementation of exactly that scientific-evidential approach. (shrink)

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

This book is a comprehensive and unique text and reference in medical ethics. By far the most inclusive set of primary documents and articles in the field ever published, it contains over 100 selections. Virtually all pieces appear in their entirety, and a significant number would be difficult to obtain elsewhere. The volume draws upon the literature of history, medicine, philosophical and religious ethics, economics, and sociology. A wide range of topics and issues are covered, such as law and (...) medicine, truth-telling by the physician, research, population policy, genetics, abortion, dying, and individual rights in medical care. The selections span the centuries, beginning with material from the works of Hippocrates, continuing through Thomas Percival, John Stuart Mill, and Claude Bernard, down to modern commentators like Henry K. Beecher, Walsh McDermott, David L. Bazelon, Paul Freund, H. L. A. Hart, John Rawls, Paul Ramsey, Richard McCormick, Rashi Fein, and Bernard Barber. The text has eight major divisions, beginning with sections on the ethical dimensions of the physician-patient relationship in history; the moral bases of medical ethics; and regulation, compulsion, and protection of the consumer in clinical medicine and public health. Each of these sections includes key essays that appear for the first time. All of the book's major divisions contain primary documents: codes such as the Hippocratic Oath, Medieval Law for the Regulation of Medicine, and the first as well as the most recent code of the American Medical Association; court decisions, including those on Karen Quinlan and on abortion in the United States and West Germany; government documents such as the statement of the National Commission on the Protection of Human Subjects, the Tuskegee Syphilis Report, the British Parliamentary debate on euthanasia, and the Council of Europe on rights of the sick and dying; and various published guidelines such as the Harvard Medical School brain death criteria, the American Hospital Association on patient's rights, and Pope Pius XII on the prolongation of life. Cases that illustrate moral dilemmas are provided for discussion purposes. Each section is preceded by a succinct editor's introduction. The documents and essays are of practical value for practitioners and students in medicine, law, ethics, and counselling, and for individual patients and groups concerned with medical care. Through encompassing divergent viewpoints, the essays and primary documents were selected to encourage humane practices and deepen understanding of the multiple traditions that shaped and do shape the development of medicine. (shrink)

This paper aims to clarify the nature of understanding in medicine. The first part describes in more detail what it means to understand something and links a type of understanding (i.e., objectual understanding) to explanations. The second part proceeds to investigate what objectual understanding of a disease (i.e., biomedical understanding) requires by considering the case of scurvy from the history of medi- cine. The main hypothesis is that grasping a mechanistic explanation of a condi- tion is necessary for a (...) biomedical understanding of that condition. The third part of the paper argues that biomedical understanding is necessary, but not sufficient for understanding in a clinical context (i.e., clinical understanding). The hypothe- sis is that clinical understanding combines biomedical understanding of a disease or pathological condition with understanding illness, which involves some degree of personal understanding of the patient. It is argued that, in many cases, clinical understanding necessitates adopting a particular second-personal stance and using cognitive resources in addition to those involved in biomedical understanding. (shrink)

The use of evidence in medicine is something we should continuously seek to improve. This book seeks to develop our understanding of evidence of mechanism in evaluating evidence in medicine, public health, and social care; and also offers tools to help implement improved assessment of evidence of mechanism in practice. In this way, the book offers a bridge between more theoretical and conceptual insights and worries about evidence of mechanism and practical means to fit the results into evidence (...) assessment procedures. (shrink)

In this paper we argue that knowledge in health care is a multidimensional dynamic construct, in contrast to the prevailing idea of knowledge being an objective state. Polanyi demonstrated that knowledge is personal, that knowledge is discovered, and that knowledge has explicit and tacit dimensions. Complex adaptive systems science views knowledge simultaneously as a thing and a flow, constructed as well as in constant flux. The Cynefin framework is one model to help our understanding of knowledge as a personal construct (...) achieved through sense making. Specific knowledge aspects temporarily reside in either one of four domains – the known, knowable, complex or chaotic, but new knowledge can only be created by challenging the known by moving it in and looping it through the other domains. Medical knowledge is simultaneously explicit and implicit with certain aspects already well known and easily transferable, and others that are not yet fully known and must still be learned. At the same time certain knowledge aspects are predominantly concerned with content, whereas others deal with context. Though in clinical care we may operate predominately in one knowledge domain, we also will operate some of the time in the others. Medical knowledge is inherently uncertain, and we require a context-driven flexible approach to knowledge discovery and application, in clinical practice as well as in health service planning. (shrink)

This article investigates five kinds of vagueness in medicine: disciplinary, ontological, conceptual, epistemic, and vagueness with respect to descriptive-prescriptive connections. First, medicine is a discipline with unclear borders, as it builds on a wide range of other disciplines and subjects. Second, medicine deals with many indistinct phenomena resulting in borderline cases. Third, medicine uses a variety of vague concepts, making it unclear which situations, conditions, and processes that fall under them. Fourth, medicine is based on (...) and produces uncertain knowledge and evidence. Fifth, vagueness emerges in medicine as a result of a wide range of fact-value-interactions. The various kinds of vagueness in medicine can explain many of the basic challenges of modern medicine, such as overdiagnosis, underdiagnosis, and medicalization. Even more, it illustrates how complex and challenging the field of medicine is, but also how important contributions from the philosophy can be for the practice of medicine. By clarifying and, where possible, reducing or limiting vagueness, philosophy can help improving care. Reducing the various types of vagueness can improve clinical decision-making, informing individuals, and health policy making. (shrink)

This volume introduces readers to the main philosophical issues of measurement in medicine, illustrating the connections between the natural and social sciences by integrating essays on causation, measuring instruments and issues of measurement and policy.

Phenomenology is a useful methodology for describing and ordering experience. As such, phenomenology can be specifically applied to the first person experience of illness in order to illuminate this experience and enable health care providers to enhance their understanding of it. However, this approach has been underutilized in the philosophy of medicine as well as in medical training and practice. This paper demonstrates the usefulness of phenomenology to clinical medicine. In order to describe the experience of illness, we (...) need a phenomenological approach that gives the body a central role and acknowledges the primacy of perception. I present such a phenomenological method and show how it could usefully illuminate the experience of illness through a set of concepts taken from Merleau-Ponty. His distinction between the biological body and the body as lived, analysis of the habitual body, and the notions of motor intentionality and intentional arc are used to capture the experience of illness. I then discuss the applications this approach could have in medicine. These include narrowing the gap between objective assessments of well-being in illness and subjective experiences which are varied and diverse; developing a more attuned dialogue between physicians and patients based on a thick understanding of illness; developing research methods that are informed by phenomenology and thus go beyond existing qualitative methods; and providing medical staff with a concrete understanding of the impact of illness on the life-world of patients. (shrink)

This paper examines the way in which causal relations are understood in the dominant model in contemporary medicine. It argues that the causal relation is not definable in terms of the condition relation, but that in general for conditions of an occurrence to be among its causes they must answer instrumental interests in a certain way, and there are further criteria for distinguishing 'the' cause of a disease (i.e., its etiological agent) from other causal factors, which are based upon (...) instrumental interests peculiar to medicine. It also argues that diseases are complex processes of which both clinical and underlying patho-physiological manifestations are proper parts (as contrasted with effects). (shrink)

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances of intentional wrongdoing, by males in nonacademic medical settings, with oversight problems and a selfish motive such as financial gain or sex. More than half of cases involved a wrongdoer (...) with a suspected personality disorder or substance use disorder. Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions. (shrink)

This paper aims to clarify the nature of understanding in medicine. The first part describes in more detail what it means to understand something and links a type of understanding (i.e., objectual understanding) to explanations. The second part proceeds to investigate what objectual understanding of a disease (i.e., biomedical understanding) requires by considering the case of scurvy from the history of medicine. The main hypothesis is that grasping a mechanistic explanation of a condition is necessary for a biomedical (...) understanding of that condition. The third part of the paper argues that biomedical understanding is necessary, but not sufficient for understanding in a clinical context (i.e., clinical understanding). The hypothesis is that clinical understanding combines biomedical understanding of a _disease_ or pathological condition with understanding _illness,_ which involves some degree of personal understanding of the patient. It is argued that, in many cases, clinical understanding necessitates adopting a particular second-personal stance and using cognitive resources _in addition_ to those involved in biomedical understanding. (shrink)

Intuition is frequently used in medicine. Along with the use of existing medical rules, there is a separate channel that physicians rely on when making decisions: their intuition. To cope with the epistemic problem of using intuition, I use some clues from Wittgenstein's philosophy to illuminate the decision-making process in medicine. First, I point to a connection between intuition as functioning in medicine and Wittgenstein's notions of "seeing as" or noticing "aspects". Secondly, I use Wittgenstein notion of (...) empirical regularities hardened into rules to suggest that there are two stages that should be addressed in the analysis of medical practice: the first concerns the accumulation of cases and the second pertains to the setting a rule based on these cases. I argue further that the medical context is exceptional in that the two stages are intertwined and, and explain the consequences of this fact for the physician's work. Finally, inspired by Wittgenstein's rule-following conundrum, I argue that medicine is particularly prone to difficulties in applying a general rule to a specific case represented by an individual patient. Recourse to intuition is reflects the physicians' efforts to bridge this gap. (shrink)

We have never been so aware of masks. They were in short supply in the early days of COVID-19, resulting in significant risk to health care workers. Now they are highly politicized with battles about mask-wearing protocols breaking out in public. Although masks have obtained a new urgency and ubiquity in the context of COVID-19, people have thought about both the literal and metaphorical role of masks in medicine for generations. In this paper, we discuss three such metaphors—the masks (...) of objectivity, of infallibility, and of benevolence—and their powerful role in medicine. These masks can be viewed as inflexible barriers to communication, contributing to the traditional authoritarian relationship between doctor and patient and concealing the authenticity and vulnerability of physicians. COVID masks, by contrast, offer a more nuanced and morally complex metaphor for thinking about protecting people from harm, authentic and trustworthy communication, and attention to potential inequities both in and beyond medical settings. We highlight the morally relevant challenges and opportunities that masks evoke and suggest that there is much to be gained from rethinking the mask metaphor in medicine. (shrink)

Medical professionals regularly joke about their patients' problems. Some of these jokes are clearly wrong, but are all jokes wrong?

How, in a secular world, should we resolve ethically controversial and troubling issues relating to health care? Should we, as some argue, make a clean sweep, getting rid of the Hippocratic ethic, such vestiges of it as remain? Jennifer Jackson seeks to answer these significant questions, establishing new foundations for a traditional and secular ethic which would not require a radical and problematic overhaul of the old. These new foundations rest on familiar observations of human nature and human needs. Jackson (...) presents morality as a loose anatomy of constituent virtues that are related in different ways to how we fare in life, and suggests that in order to address problems in medical ethics, a virtues-based approach is needed. Throughout, attention is paid to the role of philosophy in medical ethics, and how it can be used to clarify key notions and distinctions that underlie current debates and controversial issues. By reinstating such concepts as justice, cardinal virtue, and moral duty, Jackson lays the groundwork for an ethics of health care that makes headway toward resolving seeming dilemmas in medical ethics today. This penetrating and accessible book will be invaluable to students of sociology and health care, as well as those who are interested in the ethical uncertainties faced by the medical world. (shrink)

A Charter on Medical Professionalism (CMA) has just recently been developed internationally, and the Canadian Medical Association is calling for public dialogue on medical professionalism now that reforms in the Canadian system of health care are imminent. We posit that good practices are at issue; we outline the essence of these in general and also specifically in the knowing, teaching and intervening components of practice. We also see challenges not to, but in, medical professionalism – first and foremost in the (...) profession's definition of good practices and the payer's confinement of insurance coverage to these. (shrink)

Colgrove challenges Doug Hardman’s account of deception in medicine. Hardman contends physicians can unintentionally deceive their patients, illustrating this by way of an acupuncturist who believes what she says despite insufficient medical evidence, falling short of what Hardman believes adequate disclosure requires. Colgrove argues deception requires intent but constructs an alternative case in which an acupuncturist does not believe what he tells the patient, but purportedly lacks an intent to deceive. Here, I argue that both acupuncturists deceive, and both (...) can be said to do so intentionally. Neither lies, but rather they seem to engage another deceptive form of speech, what Frankfurt calls bullshit. Building on Colgrove’s case, I argue cases where a physician’s disclosure includes reading a script they do not believe, this is both deceptive and contrary to professional medical ethics. (shrink)

Providing a concise definition of hope is challenging. Psychologists alone have proposed 26 theories of hope and 54 definitions thereof. The difficulty of finding a universal definition of hope was summed up by the philosopher Joseph Godfrey who admitted, "I'd rather have hope than be able to define it". Part of the problem is that the concept is the object of scrutiny across many different scholarly disciplines, each of which have their own, sometimes divergent, methodologies and interests in the concept. (...) Notwithstanding these idiosyncrasies, many of the respective disciplines, if not all, have the potential to improve the understanding of... (shrink)

Trust relations in medicine are argued to be a requisite response to the special vulnerability of persons as patients. Even so, the problem of motivating trust remains a vital concern. On this score, it is argued that a strong motivation can be found in recognizing that professional self-interest actually entails cultivation of patient trust as a means to maintain professional self-governance. And while the initial move to restore trust must be provoked from such narrow concerns, the process of sustaining (...) trust will require educational initiatives aimed at restoring attitudes and skills suggestive of Percival's concept of empathic care. By including such initiatives, future waves of medical professionals are apt to sustain trust with deepened commitments to character, care, and trust as constitutive properties of their professional mission. (shrink)

What is considered normal determines clinical practice in medicine and has implications at an individual level, doctor-patient relationship and health care policies. With the increase in medical information and technical abilities it is urgent to have a clear concept of normality in medicine so that crucial discussions can be held with unequivocal terms.The different meanings for normality were analyzed throughout the literature and grouped according to their relevance in the academic community in models, namely the Biostatistical Theory (BST), (...) Health, Ideal, Process and Biological advantage. The BST is the most established naturalistic approach, however normal variability can arguably constitute a problem. Health is similar and raises the question of setting the boundaries of pathology. Normality as an Ideal is an useful tool but is naturally unrealistic. As a Process it is comprehensible but is hard to frame for practical purposes. If considered as a Biological Advantage, seems intuitive but abnormality should tend to disappear.After, three examples were presented to discuss these models. They were Anemia, Psychiatric diseases and Psychopathy. In the case of Anemia the BST was applied and the arbitrary boundaries but with social impact were exposed. Psychiatric diseases was discussed under the process of self-organization and non-suffering ideal. With Psychopathy the boundaries of biological advantage are questioned.This review appeals to the importance of redesigning of the concept of normality in medicine according to current times and stresses the importance of integrating concepts such as variability and autonomy. (shrink)

Over the past decades, public trust in medical professionals has steadily declined. This decline of trust and its replacement by ever tighter regulations is increasingly frustrating physicians. However, most discussions of trust are either abstract philosophical discussions or social science investigations not easily accessible to clinicians. The authors, one a surgeon-turned-philosopher, the other an analytical philosopher working in medical ethics, joined their expertise to write a book which straddles the gap between the practical and theoretical. Using an approach grounded in (...) the methods of conceptual analysis found in analytical philosophy which also draws from approaches to medical diagnosis, the authors have conceived an internally coherent and comprehensive definition of trust to help elucidate the concept and explain its decline in the medical context. This book should appeal to all interested in the ongoing debate about the decline of trust - be it as medical professionals, medical ethicists, medical lawyers, or philosophers. (shrink)

One of the cornerstones of modern medicine is the search for what causes diseases to develop. A conception of multifactorial disease causes has emerged over the years. Theories of disease causation, however, have not quite been developed in accordance with this view. It is the purpose of this paper to provide a fundamental explication of aspects of causation relevant for discussing causes of disease.The first part of the analysis will discuss discrimination between singular and general causality. Singular causality, as (...) in the specific patient, is a relation between a concrete sequence of causally linked events. General causation, e.g. as in disease etiology, means various categories of causal relations between event types. The paper introduces the concept of a reference case serving as a source for causal inference, reaching beyond the concept of general causality. (shrink)