Readers for draft chapters of “Philosophy of Medicine”

I’m committed to producing draft chapters of my book “Philosophy of Medicine” (under contract with Oxford) over the coming three months, since it’s being used for to teach a course. I would appreciate any other readers, for part or whole, and if you would like to receive draft chapters as I go along, please let me know. Here’s an outline with dates the drafts will be ready. I’m also attaching the 2 page preface: About This Book.

Chapter 1: What Is Philosophy of Medicine? (3 Jan) sets out the approach of the book. It suggests that many topics in the Philosophy of Medicine can be seen as contributing, more or less directly, towards answering the question “What is medicine?” The chapter also introduces my idea about the answer, which is the Inquiry Thesis: that medicine is an inquiry into health and illness, and the reasons for them. The chapter sets out some methodological ideas, arguing that conceptual analysis alone is inadequate for Philosophy of Medicine, and emphasizing the importance of historical, sociological and anthropological awareness. The Chapter also includes a cursory historical survey of medicine.

Chapter 2: Medical Competence (10 Jan) asks what medical professionals do, that distinguishes them from other professionals. In this Chapter I develop my idea that medicine is an inquiry, and argue that medicine cannot be fully understood merely as the business of delivering cure.

Chapter 3: Evidence Based Medicine (17 Jan) considers the movement known by that name, arising in the 1990s. The Chapter considers both the EBM’s critiques of Mainstream Medical practice, and the various philosophical, scientific, and medical attacks on EBM. The analysis offered is that social factors were among the primary drivers in this debate, and remain prominent in its aftermath.

Chapter 4: Person-Centred Medicine (due 24 Jan) considers the idea that Mainstream Medicine wrongly focuses on the disease at the expense of the patient, or person. There are several drivers for this idea, including resistance to EBM, the hope held out by genetic advances of tailoring treatments to individuals, and good old Hippocratic attitudes. The Chapter seeks to untangle the drivers and make sense of the prescriptions of the movement.

Chapter 5: Medical Nihilism (31 Jan) considers the view that medicine is largely useless. The view was common in the days when medicine really was largely ineffective, but less common now. However it has received continued defense from both historians and philosophers. We will consider contemporary arguments for and against the view.

Chapter 6: Alternatives (7 Feb) addresses the widespread consultation of non-Mainstream traditions within Western contexts. These are often motivated by nihilism about Mainstream Medicine. Alternative therapies are politically contentious, and there are many commentators who dismiss all such therapists as quacks, and their patients as idiots. The chapter seeks a balanced understanding of the continued appeal of alternatives, by obtaining a clearer understanding of the epistemological situation of the patient.

Chapter 7: Decolonising Medicine (14 Feb) discusses medical traditions in non-Western contexts other than Mainstream Medicine. These typically predate Mainstream Medicine, but they also change considerably with time. Attention is given both to learned traditions and those that are not or generally were not written down. Particular attention is given to the sangoma of southern Africa. The fact that Mainstream Medicine enjoys certain notable successes does not remove the fact that it is shaped by a particular culture, and that it implies power relations. The Chapter seeks to understand how to steer between cultural domination, on one hand, and a loose and impractical kind of relativism on the other.

Chapter 8: Epidemiology (28 Feb) discusses the significance of this relative minnow of health sciences. Existing outside the laboratory, and coming to formality only recently, epidemiology nevertheless has played a crucial role in some of the most significant health events since the medical revolution, notably the discovery that smoking causes lung cancer. This Chapter discusses its character and its internal wrangles, especially concerning causal inference outside the laboratory setting.

Chapter 9: Social Determinants of Health (7 Mar) explores one major consequence of contemporary epidemiological research, namely the demonstration that the way society is organised plays a major role in determining health. This discovery is threatening in a number of ways, since it blurs the distinction between medicine and politics, and undermines the significance of clinical medicine for population health. The Chapter considers the arguments for and against the causal claims at stake, and draws out some of their consequences.

Chapter 10: The Nature of Health (14 Mar) considers what health is, something that must be understood if medicine is to be understood. The Chapter surveys the philosophical literature on this topic, including the standard objections to the standard views, and suggests that the way to untangle the debate is to distinguish between evaluative and realist dimensions of debate. A position according to which health is akin to a “secondary property” is also defended.

Chapter 11: Disease and Classification (21 Mar) considers what disease is. The Chapter argues that disease is not the mere absence of health (contrary to the literature treated in Chapter 10), since such a definition would render talk of different diseases nonsensical. The Chapter explores the importance of differentiation between diseases for medicine, and discusses the significance of the continued difficulties in classifying psychological diseases.

Chapter 12: What is Medicine? (28 Mar) returns to the guiding question of this book, and sets out to defend and supplement the Inquiry Thesis.



In need of a framework

Following the initial dinner at the causal inference workshop, it is clear that there are both insights and mistakes flying around. Epidemiologists are way ahead of philosophers in some respects, especially in their appreciation for the varieties of causal situation that can arise, and in their treatment of general causation and especially quantitative treatments of it. On the other hand they make some persistent errors, some of which a philosophical training would prevent, and some arising from the intrinsic difficulty of the subject. The problem, and perhaps the place where philosophical input could be most useful, is that the issues aren’t clearly partitioned, and discussions roam from one point to another, with interlocutors not clearly recognizing the logical links, or lack of them, and thus ultimately not able to separate their errors from their insights. Perhaps what I have just described sounds like many philosophical discussions too, but philosophers do characteristically–to a fault, perhaps–distinguish issues. “Ah, but that’s a different question,” is a common retort.

In the present debate, a framework within which certain issues could be separated from others, some parked and some revved up, would be very helpful. I’m not sure how to achieve it, without a huge synthesic survey of everything that has been written. Perhaps that is the only way.

How much do I owe Pinocchio?

I suspect that I would not have made it through my PhD without the institution pictured below:

During “Fall” 2006, when I was a Visiting Fellow at the above-pictured bus’s destination, Pinnochio’s was my lunchtime sustenance, the thing I looked forward to all morning as I sat in the library of the Philosophy Department wondering whether the debate between Stalnaker and Lewis on counterfactual excluded middle had any bearing on Schaffer’s contrastivist treatment of causal selection.

But wait: when I say that I would not have got through without Pinnochio’s, what exactly am I envisaging? A situation where Pinnochio’s was there but I never discovered it? A situation where it had never existed? –or where perhaps it closed just as I found it, like my second favourite, Burritos? (I still sometimes wonder what might have been.) Or perhaps a situation where Pinnochio’s existed, but didn’t do such good pizza; pizza such as this:

It is interesting to be back in the same place thinking about the same questions ten years later, and satisfying to have come quite an unpredictable route, both intellectually and geographically. In 2006 I had never heard of epidemiology, much less contemplated working on it; and when I got into epidemiology, I thought I had decided to move away from working on counterfactuals and causation. It is curious how things turn out.

I am here for a Radcliffe Institute workshop mostly centering around an upcoming special issue of the International Journal of Epidemiology on causal inference. Previously I posted links to papers in IJE earlier this year, and the special issue promises to be really interesting–a real resource, for sociologists, philosophers and perhaps historians, as well as for epidemiologists.

On the long journey from Johannesburg to Boston I read or re-read as much as I could of what has been published or written on this during 2015 and 2016. I can see some real progress. It is clear that nobody intends to restrict causal claims to those that can be relativized to a humanly feasible intervention, for example. It is also clear that at least some of the debate concerns matters of presentation. It is important to me, for example, not to be cast as a methodological Luddite who insists on putting verbiage in the way of honest, hardworking methodologists who just want to get on with the job. It is important to those methodologists, on the other hand, not to be cast as any sort of methodological fascist, intent on forcing everyone to employ a preferred set of methods, and excommunicating everyone else.

On the other hand, serious questions remain. From what I have read, the main ones are as follows.

  1. What exactly are the commitments of the Potential Outcomes Approach? Is it just a set of methods? Or something more? And if more, exactly what? I have been trying to understand this since I first started working on the topic, and in the latest paper by Vandenbroucke, Pearce, and myself, we try to set the elements of the position out. I will be hoping to find out if we got it right.
  2. The distinction between causal identification and quantitative estimation of effect size has become central. Does it bear the weight that is put on it? Does it indeed offer a domain in which the POA really can delineate either necessary or sufficient (or both) conditions for a causal inference? How are identification and estimation related?
  3. Are there sufficient conditions for causal inference, of any kind, and if so what kind of sufficiency is it?
  4. What exactly is the role of judgement? Everyone agrees it is needed. But what exactly is it, and how is it to be trained, if formal methods do not take us all the way? Although I am always pushing on the need for judgement, I have great sympathy with the formalising perspective. After all, judgement isn’t magic. If we can do it, there must be something we are doing; and if we could only describe this, we could automate it, refine it, improve it, and so forth. Yet we can’t even say what it is we are doing when we make a causal (or other inductive) inference. How can this be? An old question, obviously, but one that I think is becoming more pressing in the age of technicality.
  5. What is the broader significance of the developments of the last ten years that fall under the POA? Are they part of the development of the science towards what Kuhn would call puzzle-solving? Part of the appeal, if not the motivation, of the new methods seems to be a desire for formalising causal inference. Is this reasonable? Achievable? Healthy or not? Kuhn’s view is that scientists learn by rote, and in order to learn by rote there needs to be something to learn. A methodology that says “think about it and use your judgement” does not lend itself to this. Are these developments partly about getting epidemiology into a “normal science” phase? Of course we don’t have to believe Kuhn was right about science, but I continue to find his lens useful.
  6. What is the social and political dimension to this debate? Will the new methods render difficulty variables like race more tractable? Or will the POA enforce a certain view of them, perhaps by encouraging us to think of race as a genetic trait and not as a complex socio-historical role? Further (and this hasn’t been explicitly asked, but it occurred to me on reading) does the development of a set of methods for measuring effect sizes of interventions in increasingly difficult situations reflect the social and political interests? — certainly not of the methodologist in question, of course; I mean the larger context in which this sort of project is undertaken at Ivy League universities, gains traction, gives rise to intellectual celebrities, and so forth.

The last question in particular is uncomfortable, since it sounds unpleasantly personal. It really isn’t personal; it is not any sort of attack, and indeed it extends to this very debate, and to myself.

The two churches between my Sheraton and Pinnochio’s have signs outside saying “BLACK LIVES MATTER”. A helpful reminder, since I didn’t see many black people on my walk. Most of those I did see appeared to be homeless, so the signs must be quite affirmative for them. The other diners at Pinnochio’s were all white men: two professors having a long conversation about a running conflict with an absent colleague, and three students probably still in their teens, two of whom were in suit and tie. I think they were choristers. I was feeling right at home, until one of the youngsters said to another, “How many suits do you have?”

After a pause, the other said “Six or seven.” The way he said it I could tell he had at least twelve.

I have three, only one of which both is clean and fits me.

Had I not discovered Pinnochio’s ten years ago, perhaps two of them would fit me.