TABLE OF CONTENTS
Chapter 1. Health
DOI: 10.7208/chicago/9780226595177.003.0001
[health;naturalism;normativism;objectivism;neutralism;positive health;subjectivism]
Health is one of the primary concerns of medicine. The concept of health can be analysed on several dimensions. Some people take health to be simply the absence of disease ('neutralism'). Others take health to be something more than merely the absence of disease, such as the ability to flourish in various respects ('positive health'). Another important dimension to the concept of health is the role of the patient in determining whether or not she is healthy. Some people hold that it is only objective facts about a person that determines whether or not that person is healthy ('objectivism'). Others hold that the way a person feels about her state, regardless of objective facts about that state, determines whether or not that person is healthy ('subjectivism'). Finally, a related dimension to the concept of health is the role of normative considerations in determining whether or not a state is healthy. One view, called ‘naturalism’, holds that health is a state that depends only on natural (biological or physical) facts. A competing view, called ‘normativism’, holds that health is a state that depends on evaluative (normative) considerations. This chapter engages with these various debates about the nature of health.
Chapter 2. Disease
DOI: 10.7208/chicago/9780226595177.003.0002
[disease;naturalism;normativism;hybridism;eliminativism]
What is a disease? This foundational question dominated philosophy of medicine for a generation. It is an important question, because controversies about particular disease categories can depend on assumptions about the general nature of disease. Such controversies, in turn, can have significant practical consequences. There are two main positions on what a disease is, and two important alternatives to these positions. One prominent account of disease, called ‘naturalism’, holds that diseases are simply dysfunctioning physiological systems (this is the flip side of naturalism about health). Another prominent account of disease, called ‘normativism’, holds that diseases are disvalued states (this is the flip side of normativism about health). An alternative to these two main positions, called ‘hybridism’, is a mid-way position between naturalism and normativism, and holds that diseases are dysfunctioning physiological systems which bring harm to those with the dysfunction. Another alternative, called ‘eliminativism’, holds that medicine can get by without a conceptual account of disease. This chapter investigates these conceptions of disease.
Chapter 3. Death
DOI: 10.7208/chicago/9780226595177.003.0003
[death;biological death;personhood;abortion;euthanasia]
Death is a central part of medicine. One aim of medicine is to intervene on diseases to avoid death. So an assumption of medical practice is that death is something to be avoided. Why should we strive so hard to avoid death? Is death so bad? Another fundamental question is: what is death? Most of us hold an untutored view that death involves the permanent cessation of biological functioning of an organism. However, although the death of an organism is important in medicine, there is another kind of death that is important, namely, death of a person. Personhood is an important theoretical concept in our moral thinking. There are reasons to think that death of an organism may be sufficient for death of a person (though some argue against that), but there are reasons to thinking that death of an organism is not necessary for death of a person. This chapter explores these puzzling issues. Having a well-grounded theoretical understanding of death gives us a more sophisticated way to think about the ethics of killing in the context of medicine (abortion, euthanasia, and the withdrawal of life support).
Chapter 4. Causation and Kinds
DOI: 10.7208/chicago/9780226595177.003.0004
[causation;natural kinds;monocausal model;multifactorial model;nosology;precision medicine;personalised medicine]
This chapter begins with introducing three fundamental theories of causation, before proceeding to models of disease causation. Nosology is the study of disease classification. Philosophers have long been concerned withelucidating the basis of ‘natural kinds’. Natural kinds are categories that reflect real divisions in nature. The aim in nosology is to develop disease categories that are natural kinds. A key distinction when discussing disease causation is between ‘monocausal models of disease’ and ‘multifactorial models of disease’. Monocausal models of disease identify single necessary and sufficient causes for a particular disease, whereas multifactorial models of disease hold that the causal basis of many diseases is too complex for that. Infectious diseases are good examples of monocausal models of disease, while chronic diseases such as type 2 diabetes are good examples of multifactorial models of disease. This chapter investigates these two models, and ultimately asks if the distinction is in fact as sharp as it’s usually made out to be. Precision medicine (also called personalised medicine) involves an attempt to define disease categories in the finest-grained way possible, according to knowledge about the ethological and pathophysiological basis of diseases. This chapter evaluates the promise of precision medicine.
Chapter 5. Holism and Reductionism
DOI: 10.7208/chicago/9780226595177.003.0005
[reductionism;holism;biomedical model;biopsychosocial model]
Medical reductionism holds that diseases should be understood in the finest-grained way possible, by defining diseases according to the abnormal microphysiological parts that constitute diseases, and that medical interventions should target those microphysiological parts. Reductionism in medicine is sometimes called the ‘biomedical’ model of medicine. However, reductionism in medicine ignores the broader contexts in which diseases arise, such as social and economic contexts. Medical reductionism has failed to develop effective treatments for a wide range of diseases. Reductionism is associated with viewing patients as mere bodies to be intervened on, rather than people to be cared for. An alternative view is called holism. In medicine, holism is a view of diseases, interventions, and patients that attempts to remedy these reductionist shortcomings. Holism considers the object of medical intervention as the whole person rather than a particular disease entity. In contrast to the biomedical model, some people speak of a biopsychosocial model, which holds that we must consider more than just the biological features of patients when thinking about and intervening on diseases. This chapter assesses various debates between reductionism and holism in medicine.
Chapter 6. Controversial Diseases
DOI: 10.7208/chicago/9780226595177.003.0006
[controversial disease;addiction;depression;medicalisation;disease creep;culture-bound syndrome]
Many diseases in medicine are controversial. Critics claim that some diseases are not ‘real’. This criticism is especially salient in psychiatry. A related claim that some critics make is that normal aspects of human life get ‘medicalised’—normal human traits get inaptly brought into the scope of medical attention (such as depression or addiction). Another reason why some diseases are controversial is the phenomenon of ‘disease creep’, which occurs when standards for diagnosing a disease become easier and easier to meet, rendering more and more people diagnosable with the disease, to the point where healthy people are spuriously diagnosed as diseased. Some alleged diseases are ‘culture bound’—they exist only in a particular time and place. This chapter addresses some of the above aspects of controversial diseases, and arguments proposed by critics and defenders of controversial diseases.
Chapter 7. Evidence in Medicine
DOI: 10.7208/chicago/9780226595177.003.0007
[evidence;bias;randomised trial;RCT;meta-analysis;mechanism]
One of the most important types of research in medicine is to find effective ways to intervene on diseases. Medical research is prone to many forms of bias, and sometimes fraud. Medical researchers respond to concerns about bias by introducing methodological safeguards. In this chapter, we examine some prominent forms of bias in medical research. The most important method for measuring effectiveness of interventions is the randomised trial. The main feature that distinguishes randomised trials as reliable, according to proponents, is that the allocation of subjects to the experimental and control group of studies is done randomly—this is called a randomised controlled trial (RCT). But the importance of randomisation is debated. Many people hold meta-analyses of RCTs to be the definitive empirical basis of evaluating medical interventions, but this too is controversial. Another research strategy is to supplement findings from population-level studies such as RCTs with knowledge of mechanisms. But the importance of mechanisms is also debated. This chapter introduces these debates.
Chapter 8. Objectivity and the Social Structure of Science
DOI: 10.7208/chicago/9780226595177.003.0008
[objectivity;social objectivity;publication bias;conflict of interest;bias;values in science]
In science, objectivity can be a term that applies to research methods or to the evidence generated by such methods (or sometimes, to scientists themselves). Objectivity of a research method pertains to the extent to which that method is free from systematic errors. Objectivity can also be a property that applies to the community-level of science: a scientific community can be organised and act in ways that are more or less conducive to truth. In this chapter the focus is on ‘social objectivity’—the possible errors that come about due to shortcomings in the social structure of the scientific community, and the various ways that the community structure of medical science can mitigate such errors and thereby achieve some degree of objectivity. Publication bias and conflicts of interest that arise due to industry funding of research are two important problems in medical science, so we start the chapter with discussions of these problems. The influence of (non-epistemic) values on medical science is a threat to its objectivity. One possible resolution is to try to mitigate these threats by implementing epistemological tactics at the social level.
Chapter 9. Inference
DOI: 10.7208/chicago/9780226595177.003.0009
[inference;statistics;Bayesianism;frequentism;outcome measures]
The dominant view among regulators and evidence-based medicine is that evidence from randomised trials can be used directly, to make a very simple inference about the effectiveness of an intervention. This chapter describes criticisms of this view. The critical view argues that inferences about effectiveness cannot be direct, but rather must be modulated in various ways. This chapter examines the various ways that causal inference goes beyond direct inference from randomised trials. Moreover, before data from studies can be used in a causal inference, it has to be quantitatively summarised in particular ways (using 'outcome measures'), but there are multiple possible ways to do this, and these can lead to different judgments about effectiveness. Causal inference in medicine is almost always statistical in nature. The two main theories of scientific inference are frequentism and Bayesianism, and each has merits and drawbacks. This chapter assesses these two theories of statistical inference here. This chapter is perhaps the most technical of the book. But it is important to learn this technicalia, because much recent philosophy of science and medicine uses these technical tools, and these tools help us to properly understand medicine.
Chapter 10. Effectiveness, Skepticism, and Alternatives
DOI: 10.7208/chicago/9780226595177.003.0010
[effectiveness;medical nihilism;therapeutic nihilism;alternative medicine;homeopathy;acupuncture;placebo]
This chapter starts by examining various positions on what is required for a medical intervention to be deemed effective, and then addresses a long-standing debate among physicians, epidemiologists, and philosophers: is medicine effective? Surprisingly, many healthcare practitioners and medical scientists (and a few philosophers) have raised doubts about the capacity of medicine to improve health by targeting diseases. This skeptical view is sometimes called ‘therapeutic nihilism’ or ‘medical nihilism’. This chapter assesses the arguments for medical nihilism. What about alternative medicine? Many people use alternative medicine, such as homeopathy and acupuncture. Is there anything to be said in favour of this? A straightforward dismissive answer notes that the vast majority of trials that have tested alternative medicine show it to be no better than placebo, and thus alternative medicine is not effective. However, this dismissive answer is too hasty. The question about the effectiveness of alternative medicine, it turns out, is puzzling. The chapter ends by investigating the notion of placebo and asks whether or not placebos can be deemed effective.
Chapter 11. Diagnosis and Screening
DOI: 10.7208/chicago/9780226595177.003.0011
[diagnosis;probabilitiy;false positive;false negative;screening;overdiagnosis;underdiagnosis]
Diagnosis involves the consideration of signs, symptoms, background information, and results of diagnostic tests, in order to infer that a person has a particular disease. The probabilistic nature of diagnostic tests has long served as an illustration of inductive reasoning for theories of statistical inference. This chapter begins with describing some of the core logical features underlying medical tests. False positives and false negatives can have serious practical consequences. False positives can lead to needless stress and anxiety and sometimes needless treatments, while false negatives can lead to people foregoing potentially helpful treatments. Screening involves the routine administration of tests to asymptomatic people, in an attempt to find diseases at earlier rather than later stages. There are debates about whether or not particular kinds of people should be screened for particular diseases. For example, should women under the age of forty receive regular mammograms? There are practical consequences of both too much screening and too little screening. Too much screening can lead to false positives, more invasive forms of screening such as biopsies, ‘overdiagnosis’, and subsequently ‘overtreatment’. Too little screening has the opposite problem: it can lead to ‘underdiagnosis’ and hence ‘undertreatment’. This chapter assesses aspects of these debates.
Chapter 12. Psychiatry: Care or Control?
DOI: 10.7208/chicago/9780226595177.003.0012
[pscyhiatry;mental illness;nosology;anti-psychiatry;delusion]
Psychiatry is the branch of medicine that is concerned with diagnosing and treating mental illness, or diseases of the mind. Because the object of psychiatry is the mind, the theory and practice of psychiatry is complicated and relies on premises of varying philosophical credentials. This chapter introduces some of the central questions in philosophy of psychiatry. Disease classification systems (nosology) can be based on the etiological causal basis of diseases, the pathophysiological constitutive causal basis of diseases, or the symptoms of diseases. Most of medicine uses one of the first two kinds of classification systems, while psychiatry almost exclusively uses a symptom-based classification system. This is problematic for a number of reasons described in this chapter. Some critics hold that psychiatry's aim and function is to control deviant behaviour. On this account, the ambition of psychiatry is similar to the ambition of legal or religious systems of control: behaviour which does not fit with societal norms gets categorised as a disease and controlled with surveillance, with pharmaceuticals, and sometimes even with enforced hospital admission. The chapter ends by studying the nature of delusions, and the justification of context-based diagnostic exclusionary criteria.
Chapter 13. Policy
DOI: 10.7208/chicago/9780226595177.003.0013
[policy;intellectual property;patents;research priorities;regulation]
This chapter addresses several policy questions that are relevant to medical research. Before any research is performed, scientists must determine what problems to study. There are two broad motivations to pursue a research question: intellectual curiosity and practical importance. Because medicine is by its nature practical, the motivation of practical importance is dominant. But what makes a research question important? And who should decide? Another important philosophical question pertinent to policy about medical science is whether or not the products of medical research should be protected by intellectual property laws. Many discoveries in science, including medical science, are protected by such laws, which give control to the discoverer over the manufacture and sale of that which is discovered (such as a new drug). Recently, however, these laws have been criticised, especially in the domain of medicine. This chapter studies the main arguments that have been raised to justify intellectual property laws, and then assesses their plausibility when applied to medical science. This chapter also assesses philosophical questions pertaining to regulatory policy. Some critics claim that regulators are too strict, while other critics claim that regulators are not strict enough. This chapter examines the arguments on both sides.
Chapter 14. Public Health
DOI: 10.7208/chicago/9780226595177.003.0014
[public health;social epidemiology;preventive medicine;health inequalities]
Public health is a branch of medicine that is concerned with the health of populations, the population-level causes of disease, and interventions that are administered to populations to improve health. The discipline of ‘social epidemiology’ investigates social factors that influence health, such as the influence of poverty on rates of obesity. An influential thesis is that such social factors have been the dominant cause of improvements to health that industrial societies have experienced. In other words, these improvements in health are less the result of medical interventions (like new drugs) and more the result of public health measures (such as access to clean drinking water) and improvements in social conditions (such as greater socioeconomic equality). This chapter assesses this thesis. A major endeavour of public health is known as ‘preventive medicine’. The basic idea of preventive medicine is simple: we ought to strive towards avoiding the development of new cases of disease. However, preventive medicine pushes the boundary of the domain of medicine. One puzzle about preventive medicine is that the vast majority of people who use preventive interventions do not benefit from them. Finally, this chapter ends by investigating some nuances of health inequalities.
