Philosophy of Medicine provides a fresh and comprehensive treatment of the topic. It offers a novel theory of the nature of medicine, and proposes a new attitude to medicine, aimed at improving the quality of debates between medical traditions and facilitating medicine's decolonization.

This chapter explores the idea that causal inference is warranted if and only if the mechanism underlying the inferred causal association is identified. This mechanistic stance is discernible in the epidemiological literature, and in the strategies adopted by epidemiologists seeking to establish causal hypotheses. But the exact opposite methodology is also discernible, the black box stance, which asserts that epidemiologists can and should make causal inferences on the basis of their evidence, without worrying about the mechanisms that might underlie their (...) hypotheses. I argue that the mechanistic stance is indeed a bad methodology for causal inference. However, I detach and defend a mechanistic interpretation of causal generalisations in epidemiology as existence claims about underlying mechanisms. (shrink)

Nineteenth-century medical advances were entwined with a conceptual innovation: the idea that many cases of disease which were previously thought to have diverse causes could be explained by the action of a single kind of cause, for example a certain bacterial or parasitic infestation. The focus of modern epidemiology, however, is on chronic non-communicable diseases, which frequently do not seem to be attributable to any single causal factor. This paper is an effort to resolve the resulting tension. The paper criticises (...) the monocausal model of disease, so successful in the nineteenth century. It also argues that a multifactorial model of disease can only be satisfactory if it amounts to more than a mere rejection of the monocausal model. A third alternative, the contrastive model, is proposed and defended on the grounds that it links the notions of disease and of general explanation, while avoiding the philosophical naiveties and practical difficulties of the monocausal model. (shrink)

When is a cause of a cause of an effect also a cause of that effect? The right answer is either Sometimes or Always . In favour of Always , transitivity is considered by some to be necessary for distinguishing causes from redundant non-causal events. Moreover transitivity may be motivated by an interest in an unselective notion of causation, untroubled by principles of invidious discrimination. And causal relations appear to add up like transitive relations, so that the obtaining of the (...) overarching relation is not independent of the obtaining of the intermediaries. On the other hand, in favour of Sometimes , often we seem not to treat events that are very spatiotemporally remote from an effect as its causes, even when connected to the effect in question by a chain of counterfactual or chance-raising dependence. Moreover cases of double prevention provide counterexamples to causal transitivity even over short chains. According to the argument of this paper, causation is non-transitive. Transitizing causation provides no viable account of causal redundancy. An unselective approach to causation may motivate resisting the distance counterexamples to transitivity, but it does not help with double prevention, and even makes it more intractable. The strongest point in favour of transitivity is the adding up of causal relations, and this is the point that extant non-transitizing analyses have not adequately addressed. I propose a necessary condition on causation that explains the adding up phenomenon. In doing so it also provides a unifying explanation of distance and double prevention counterexamples to transitivity. (shrink)

This paper takes it as a premise that a distinction between matters of fact and of law is important in the causal inquiry. But it argues that separating factual and legal causation as different elements of liability is not the best way to implement the fact/law distinction. What counts as a cause-in-fact is partly a legal question; and certain liability-limiting doctrines under the umbrella of “legal causation” depend on the application of factual-causal concepts. The contrastive account of factual causation proposed (...) in this paper improves matters. This account more clearly distinguishes matters of fact from matters of law within the cause-in-fact inquiry. It also extends the scope of cause-in-fact to answer some questions currently answered by certain doctrines of legal causation—doctrines that, it is argued, are more naturally seen as applications of our ordinary causal concept than as noncausal liability-limiting devices. (shrink)

In the literature on health, naturalism and normativism are typically characterized as espousing and rejecting, respectively, the view that health is objective and value-free. This article points out that there are two distinct dimensions of disagreement, regarding objectivity and value-ladenness, and thus arranges naturalism and normativism as diagonal opposites on a two-by-two matrix of possible positions. One of the remaining quadrants is occupied by value-dependent realism, holding that health facts are value-laden and objective. The remaining quadrant, which holds that they (...) are non-objective but value-free, is unexplored. The article endorses a view in the latter quadrant, namely, the view that health is a secondary property. The article argues that a secondary property framework provides the resources to respond to the deepest objections to a broadly Boorsean account of natural function, and so preserves the spirit, though not the letter, of that account. Treating health as a secondary property permits a naturalistic explanation—specifically, an evolutionary explanation—of the health concept, in terms of the assistance such a concept might have provided to the survival and reproduction of those organisms that had it. This provides the explanation, missing from Boorse's account, for the fact that function is determined with reference to the contribution to the goals of survival and reproduction, relative to the age of the sex of the species, rather than some other equally natural goals or reference classes. _1_ Introduction _2_ Two Ways to Disagree about Health _3_ Secondary Properties _4_ Health as a Secondary Property _5_ Conclusion. (shrink)

What is medicine? One obvious answer in the context of the contemporary clinical tradition is that medicine is the process of curing sick people. However, this “curative thesis” is not satisfactory, even when “cure” is defined generously and even when exceptions such as cosmetic surgery are set aside. Historian of medicine Roy Porter argues that the position of medicine in society has had, and still has, little to do with its ability to make people better. Moreover, the efficacy of medicine (...) for improving population health has been famously doubted by historians and epidemiologists. The curative thesis demands that we have mostly been stupid, duped, or staggeringly hopeful, given that medicine has not until recently offered more than a handful of effective cures. I suggest, in this article, that the core medical competence is neither to cure, nor to prevent, disease, but to understand and to predict it. I argue that this approach does a better job than the curative thesis at explaining why not all medicine is concerned with curative efforts and that it enjoys historical support from the ancient entanglement of prophecy and medicine and from the fact that medicine thrived for centuries with almost no effective cures and continues to thrive today in various forms that are mostly without curative efficacy. I suggest that this approach grounds a fairer approach to alternative, traditional, and other medical practices, as well as some fresh lessons for the development of mainstream medicine. (shrink)

According to the evolutionary sceptic, the fact that our cognitive faculties evolved radically undermines their reliability. A number of evolutionary epistemologists have sought to refute this kind of scepticism. This paper accepts the success of these attempts, yet argues that refuting the evolutionary sceptic is not enough to put any particular domain of beliefs – notably scientific beliefs, which include belief in Darwinian evolution – on a firm footing. The paper thus sets out to contribute to this positive justificatory project, (...) underdeveloped in the literature. In contrast to a ‘wholesale’ approach, attempting to secure justification for all of our beliefs on the grounds that our belief-forming mechanisms evolved to track truth, we propose a ‘piecemeal’ approach of assessing the reliability of particular belief-forming mechanisms in particular domains. This stands in contrast to the more familiar attempt to transfer warrant obtained for one domain to another by showing how one is somehow an extension of the other. We offer a naturalist reply to the charge of circularity by appealing to reliabilist work on the problem of induction, notably Peter Lipton's distinction between self-certifying and non-self-certifying inductive arguments. We show how, for scientific beliefs, a non-self-certifying argument might be made for the reliability of our cognitive faculties in that domain. We call this strategy Humean Bootstrapping. (shrink)

Commonly we distinguish the strike of a match, as a cause of the match lighting, from the presence of oxygen, as a mere condition. In this paper I propose an account of this phenomenon, which I call causal selection. I suggest some reasons for taking causal selection seriously, and indicate some shortcomings of the popular contrastive approach. Chief among these is the lack of an account of contrast choice. I propose that contrast choice is often just the counterfactual scenario in (...) which the effect does not occur: I suggest that if c causes e , then if e hadn't occurred, c wouldn't have occurred. I argue that this is a necessary condition on causation which causes meet but mere conditions fail. (shrink)

The counterfactual analysis of causation has focused on one particular counterfactual conditional, taking as its starting-point the suggestion that C causes E iff (C E). In this paper, some consequences are explored of reversing this counterfactual, and developing an account starting with the idea that C causes E iff (E C). This suggestion is discussed in relation to the problem of pre-emption. It is found that the 'reversed' counterfactual analysis can handle even the most difficult cases of pre-emption with only (...) minimal complications. The paper closes with a discussion of the wider philosophical implications of developing a reversed counterfactual analysis, especially concerning the differentiation of causes from causal conditions, causation by absences, and the extent to which causes suffice for their effects. (shrink)

When graduate students start their studies, they usually have sound knowledge of some areas of philosophy, but the overall map of their knowledge is often patchy and disjointed. There are a number of topics that any contemporary philosopher working in any part of the analytic tradition needs to grasp, and to grasp as a coherent whole rather than a rag-bag of interesting but isolated discussions. This book answers this need, by providing a overview of core topics in metaphysics and epistemology (...) that is at once accessible and nuanced. Ten core topics are explained, and their relation to each other is clearly set out. The book emphasizes the utility of the concepts and distinctions it covers for philosophy as a whole, not just for specialist discussions in metaphysics or epistemology. The text is highly readable and may be used as the basis of a course on these topics. Recommendations for reading are included at the end of each chapter, divided into essential and further readings. The text is also suitable for people approaching philosophy from other disciplines, as an accessible primer to the central topics, concepts and distinctions that are needed to engage meaningfully in contemporary philosophical debate. (shrink)

This paper seeks to determine the significance, if any, of epidemiological evidence to prove the specific causation element of liability in negligence or other relevant torts—in particular, what importance can be attached to a relative risk > 2, where that figure represents a sound causal inference at the general level. The paper discusses increased risk approaches to epidemiological evidence and concludes that they are a last resort. The paper also criticizes the proposal that the probability of causation can be estimated (...) with reference to the RR, such that RR > 2 is necessary and sufficient for causation. It is argued, following arguments by Sander Greenland and others, that RR > 2 is not necessary for proof of specific causation, except under restrictive biological assumptions that are not known to be satisfied for any important disease, and therefore must never be required. However, the paper argues that in some circumstances RR > 2 can be sufficient to prove causation at law. This position is defended against the widely held judicial and academic view that epidemiological evidence must be accompanied by something else, particular to the case at hand, if it is to have probative force for specific causation. It is argued that far from being epistemically irrelevant, to achieve correct and just outcomes it is in fact mandatory to take epidemiological evidence into account in deciding specific causation. Failing to consider such evidence when it is available leads to error and injustice. The conclusion is that in certain circumstances epidemiological evidence of RR > 2 is not necessary to prove specific causation but that it is sufficient. This “sufficiency” is confined to circumstances where there is no other evidence, as a way of getting clear on what the epidemiological evidence says. Once we have worked out what it says, this must be weighed against the other relevant evidence, if there is any. (shrink)

This article is a reply to two critics of my “Prediction, Understanding, and Medicine,” published elsewhere in this journal issue. In that essay, I argued that medicine is best understood not as essentially a curative enterprise, but rather as one essentially oriented towards prediction and understanding. Here, I defend this position from several criticisms made of it.

In this article I seek to say what it is for something to count as a neglected disease. I argue that neglect should be defined in terms of efforts at prevention, mitigation and cure, and not solely in terms of research dollars per disability-adjusted life-year. I further argue that the trend towards multifactorialism and risk factor thinking in modern epidemiology has lent credibility to the erroneous view that the primary problem with neglected diseases is a lack of research. A more (...) restrictive contrastive model of disease is endorsed as better suited to the definition of neglected disease. (shrink)

We commonly distinguish causes from mere conditions, for example by saying that the strike caused the match to light but by failing to mention the presence of oxygen. Philosophers from Mill to Lewis have dismissed this common practice as irrelevant to the philosophical analysis of causation. In this paper, however, I argue that causal selection poses a puzzle of just the same form as Hume's sceptical challenge to the notion of necessary connection. I then propose a solution in terms of (...) a simple counterfactual. (shrink)

Causation The question, “What is causation?” may sound like a trivial question—it is as sure as common knowledge can ever be that some things cause another; that there are causes and they necessitate certain effects. We say that we know that what caused the president’s death was an assassin’s shot. But when asked why, we … Continue reading Causation →.

We are pleased to once again present to the readers of Theoretical Medicine and Bioethics papers from the Philosophy of Medicine Roundtable. Previous issues have followed the 3rd and 4th Roundtables, and the current issue presents a selection from the more than 20 papers presented at the 5th Philosophy of Medicine Roundtable, which took place in New York, at Columbia University, in November 2013. Like its predecessors, held in Birmingham, AL, Rotterdam, and San Sebastian, this Roundtable attracted speakers from around (...) the world. It also featured keynote presentations from Rita Charon of Columbia University and Ross Upshur of the University of Toronto.It may seem somewhat odd to feature a special issue on philosophy of medicine in a journal that effectively has philosophy of medicine in its title. However, a review of the contents of this journal and similar ones, such as the Journal of Medicine and Philosophy, will quickly reveal such an issue’s purpose. The dominant content of these j .. (shrink)

This paper considers an important recent contribution by Miguel Hernán to the ongoing debate about causal inference in epidemiology. Hernán rejects the idea that there is an in-principle epistemic distinction between the results of randomized controlled trials and observational studies: both produce associations which we may be more or less confident interpreting as causal. However, Hernán maintains that trials have a semantic advantage. Observational studies that seek to estimate causal effect risk issuing meaningless statements instead. The POA proposes a solution (...) to this problem: improved restrictions on the meaningful use of causal language, in particular “causal effect”. This paper argues that new restrictions in fact fail their own standards of meaningfulness. The paper portrays the desire for a restrictive definition of causal language as positivistic, and argues that contemporary epidemiology should be more realistic in its approach to causation. In a realist context, restrictions on meaningfulness based on precision of definition are neither helpful nor necessary. Hernán’s favoured approach to causal language is saved from meaninglessness, along with the approaches he rejects. (shrink)

When graduate students start their studies, they usually have sound knowledge of some areas of philosophy, but the overall map of their knowledge is often patchy and disjointed. There are a number of topics that any contemporary philosopher working in any part of the analytic tradition needs to grasp, and to grasp as a coherent whole rather than a rag-bag of interesting but isolated discussions. This book answers this need, by providing a overview of core topics in metaphysics and epistemology (...) that is at once accessible and nuanced. Ten core topics are explained, and their relation to each other is clearly set out. The book emphasizes the utility of the concepts and distinctions it covers for philosophy as a whole, not just for specialist discussions in metaphysics or epistemology. The text is highly readable and may be used as the basis of a course on these topics. Recommendations for reading are included at the end of each chapter, divided into essential and further readings. The text is also suitable for people approaching philosophy from other disciplines, as an accessible primer to the central topics, concepts and distinctions that are needed to engage meaningfully in contemporary philosophical debate. (shrink)

If there is any value in the idea that disease is something other than the mere absence of health then that value must lie in the way that diseases are classified. This paper offers further development of a view advanced previously, the 'contrastive model' of disease: it develops the account to handle asymptomatic disease ; and in doing so it relates the model to a broadly biostatistical view of health. The developments are prompted by considering cancers featuring viruses as prominent (...) causes, since these appear to amount to cases where the prescriptions of the contrastive model could be followed, but aren't. The resulting irrelevance objection claims that the contrastive model is irrelevant to medical science and practice. The paper seeks to rebut the irrelevance objection. (shrink)

This paper argues that bioethics requires analysis, which is not explicitly ethical in character. The first part of the paper argues the general point, that ethical problems can arise not only on occasions when moral values make conflicting recommendations, but also in understanding the facts. I suggest that this is particularly so where the facts are provided by the biomedical sciences, since it is often not clear how to relate their conceptual framework to that in which we frame our value (...) judgements. In the second part, I illustrate the argument by criticizing the moral conclusions drawn by the authors of a recent widely publicized study of paediatric obesity. There is a failure to translate properly these results into the language we use for moral evaluation. The case therefore illustrates exactly the analytic gap which I suggest bioethics might do more to fill. (shrink)