Jonathan Fuller writes: “In the COVID-19 pandemic, numerous models are being used to predict the future. But as helpful as they are, they cannot make sense of themselves. They rely on epidemiologists and other modelers to interpret them. Trouble is, making predictions in a pandemic is also a philosophical exercise. We need to think about hypothetical worlds, causation, evidence, and the relationship between models and reality.”
‘How do the coronavirus models generating these hypothetical curves square with the evidence? What roles do models and evidence play in a pandemic? Answering these questions requires reconciling two competing philosophies in the science of COVID-19.’ Great piece which will still be interesting a week, month, year and decade from now, unusually at present.
What is the point of philosophy? That’s a question many philosophers struggle with, not just because it is difficult to answer. That goes for many academic disciplines, including “hard” sciences and applied disciplines like economics. However, unlike physicists and economists, philosophers ought to be able to answer this question, in the perception of many. And many of us can’t, at least to our own satisfaction.
I’ve written some opinion pieces (1,2) and given some interviews during this period, and I know of a handful of other philosophers who have done so (like Benjamin Smart, Arthur Caplan, and Stefano Canali). However, I also know of philosophers who have expressed frustration at the “uselessness” of philosophy in times like these. At the same time, I’ve seen an opinion piece by a computer scientist, whose expert contribution is confined to the nature of exponential growth: something that all of us with a basic mathematical education have studied, and which anyone subject to a compound interest rate, for example through a mortgage, will have directly experienced.
Yet computer science hasn’t covered itself in glory in this epidemic. Machine learning publications claiming to be able to arrive at predictive models in a matter of weeks have been notably lacking in this episode, confirming, for me, the view that machine learning and epidemiology have yet to interact meaningfully. Why do computer scientists (only one, admittedly; most of them are surely more sensible) and philosophers have such different levels of confidence at pronouncing on matters beyond their expertise?
There are no experts on the COVID-19 pandemic
This pandemic is subject to nobody’s expertise. It’s a novel situation, and expertise is remarkably useless when things change, as economists discovered in 2008 and pollsters in 2016.
Of course, parts of the current situation fall within the domains of various experts. Infectious disease epidemiologists can predict its spread. But there is considerably more to this pandemic than predicting its spread. In particular, the prediction of the difference that interventions make requires a grasp of causal inference that is a distinct skill set from that of the prediction of a trend, as proponents of the potential outcomes approach have correctly pointed out. Likewise, the attribution, after the fact, of a certain outcome to an intervention only makes good sense when we know what course of action we are comparing that intervention with; and this may be underspecified, because the “would have died otherwise” trend is so hard to establish.
Non-infectious-disease epidemiologists may understand the conceptual framework, methodology, terminology and pitfalls of the current research on the pandemic, but they do not necessarily have better subject-specific expertise than many in public health, the medical field, or others with a grasp on epidemiological principles. Scientists from other disciplines may be worse than the layperson because, like the computer scientist just mentioned, they wrongly assume that their expertise is relevant, and in doing so either simplify the issue to a childish extent, or make pronouncements that are plain wrong. (Epidemiology is, in my view, widely under-respected by other scientists.)
Turning to economics and politics, economists can predict the outcome of a pandemic or of measures to control it only if they have input from infectious disease epidemiologists on the predictive claims whose impacts they are seeking to assess.
Moreover, the health impact of economic policies are well-studied by epidemiologists, and to some extent by health economists; but these are not typically knowledgeable about the epidemiology of infectious disease outbreaks of this nature.
Jobs for philosophers
In this situation, my opinion is that philosophers can contribute substantially. My own thinking has been around cost-benefit analysis of public health interventions, and especially the neglect of the health impact – especially in very different global locations – of boilerplate measures being recommended to combat the health impact of the virus. This is obviously a lacuna, and especially pressing for me as I sit writing this in my nice study in Johannesburg, where most people do not have a nice study. Africa is always flirting with famine (there are people who will regard this as an insult; it is not). Goldman Sachs is predicting a 24% decline in US GDP next quarter.
If this does not cost lives in Africa, that would be remarkable. It might even cost more lives than the virus would, in a region where only 3% are over 65 (and there’s no evidence that HIV status makes a difference to outcomes of COVID-19). South Africa is weeks into the epidemic and saw its first two deaths just today.
Yet the epidemiological community (at least on my Twitter feed) has entirely ignored either the consequences of interventions on health, merely pointing out that the virus will have its own economic impact even without interventions, which is like justifying the Bay of Pigs by pointing out that Castro would have killed people even without the attempted invasion. And context is nearly totally ignored. The discipline appears mostly to have fallen behind the view that the stronger the measure, the more laudable. Weirdly, those who usually press for more consideration of social angles seem no less in favour, despite the fact that they spend most of the rest of their time arguing that poverty is wrongly neglected as a cause of ill-health.
Do I sound disappointed in the science that I’m usually so enthusiastic about, and that shares with philosophy the critical study of the unknown? Here we have a virus that may well claim a larger death toll in richer countries with older populations, and a set of measures that are designed by and for those countries, and a total lack of consideration of local context. Isn’t this remarkable?
There is more to say, and many objections; I’ll write this up in an academically rigorous way as soon as I can. Meanwhile, I’ll continue to publish opinion pieces, where I think it’s useful. Right now, my point is that there’s a lot for philosophers to dissect here. I don’t mean in this particular problem, but in the pandemic as a whole. And the points don’t have to be rocket science. They can be as simple as recommending that a ban on sale of cigarettes be lifted.
What is required for us to be useful, however, is that we apply our critical thinking skills to the issue at hand. Falling in with common political groupings adds nothing unique and requires the suspension of the same critical faculties that we philosophers pride ourselves on in other contexts. This is a situation where nearly all the information on which decisions are being made is publicly available, where none of it is the exclusive preserve of a single discipline, and where fear clouds rational thought. Expert analyses of specific technical problems are also readily available. These are ideal conditions for someone trained to apply analytic skills in a relatively domain-free manner to contribute usefully.
Off the top of my head, here are a handful topic ideas:
- How to circumscribe the consequences of COVID-19 that we are interested in when devising our measures of intervention (this is an ethical spin on the issue I’m interested in above)
- The nature of good prediction (which I’ve worked on in the public health context – but there is so much more to say)
- The epistemology of testimony, especially concerning expertise, in a context of minimal information (to get us past the “trust the scientists FFS” dogma – that’s an actual quote from Twitter)
- The weighing of the rights of different groups, given the trade off between young and old deaths (COVID-19 kills almost no children, while they will die in droves in a famine)
One’s own expertise will suggest other topics, provided that the effort is to think critically rather than simply identify people with whom one agrees. I very much hope that we will not see a straightforward application of existing topics: inductive risk and coronavirus; definition of health and coronavirus; rights and coronavirus; etc. To be clear, I’m not saying that no treatment of coronavirus can mention inductive risk, definition of health, or rights; just that the treatment must start with Coronavirus. My motto in working on the philosophy of epidemiology is that my work is philosophical in character but epidemiological in subject: it is philosophical work about epidemiology. Where it suggests modifications to existing debates in philosophy, as does happen, that is great, but it’s not the purpose. The idea is to identify new problems, not to cast old ones in a new light. Perhaps there are no such things as new philosophical problems; but then again, perhaps it’s only by trying to identify new problems that we can cast new light on old ones.
Call to arms
The skill of philosophers, and the value in philosophy, does not lie in our knowledge of debates that we have had with each other. It lies in our ability to think fruitfully about the unfamiliar, the disturbing, the challenging, and even the abhorrent. The coronavirus pandemic is all these things. Let’s get stuck in.
The 2020 Sydney History and Philosophy of Science Winter School will take place from Monday 27 July to Friday 31 July. The year’s topic is the History and Philosophy of Evolutionary Medicine. The school will run for four days with an excursion on the last day.
Both history and philosophy of science have the potential to contribute to a deeper understanding of the nature and potential of Evolutionary Medicine. Some philosophers of science have examined key concepts in the field. Others have debated its potential to inform medical practice, or to transform understanding of health and disease. These debates will be explored and advanced at the Winter School. Evolutionary Medicine is underexplored in the history of science and medicine. The Winter School will explore perspectives on this history from both leading practitioners and HPS scholars. The overall aim of the Winter School is to encourage and enable philosophical and methodological commentary on evolutionary medicine, and to develop an agenda for research on evolutionary medicine by historians of science and medicine.
The Winter School will be of interest to early career researchers in history and philosophy of science, as well as to ECRs in medicine and biomedical science who want a broader perspective on Evolutionary Medicine.
Randolph M. Nesse (Arizona State University)
Tatjana Buklijas (University of Auckland)
Paul Griffiths (The University of Sydney)
Dominic Murphy (The University of Sydney)
Djuke Veldhuis (Monash University)
Applications to attend the Winter School, and applications for financial support for postgraduate students, will open with a more detailed announcement about the Winter School in February.
Please feel free to distribute this announcement to others. For all enquiries please email firstname.lastname@example.org
Organised by the School of History and Philosophy of Science, Faculty of Science, University of Sydney with support from the University of Sydney and the John Templeton Foundation.
Health as a Secondary Property
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 approach is completely distinct from evolutionary and aetiological accounts of natural functions.) 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.
2 Two Ways to Disagree about Health
3 Secondary Properties
4 Health as a Secondary Property
My book Philosophy of Medicine (Oxford University Press) has now been published in the USA, and in paperback in the UK. Hardback date in the UK is 28 March. E-books are of course available.
I am putting together a series of YouTube videos corresponding to each of the chapters, by way of segue into the fourth industrial revolution.
The book carves out some new territory in the field, by taking a broad view of medicine as something existing in different forms, in different times and places. I argue that any adequate understanding of medicine must say something about what medicine is, given this apparent variety of actual practices that are either claimed to be or regarded as medical. I argue that, while the goal of medicine is to cure, its track record in this regard is patchy at best. This gives rise to the question of why medicine has persisted despite being so commonly ineffective. I argue that this persistence shows that the business of medicine – the practice of a core medical competence – cannot be cure, even if that is the goal. Instead, what doctors provide is understanding and prediction, or at least engagement with the project of understanding health and disease.
I also cover the familiar question of the nature of health. The naturalism/normativism dichotomy is a false one, since it elides two dimensions of disagreement, one concerning objectivity, the other concerning value-ladenness. It is obvious that these are logically distinct properties. I argue that health is a secondary property, like colour, consisting in a disposition on our part to respond to an underlying reality which, however, does not carve the world in the way that our responses do. The reason that we have this disposition to respond to the underlying properties rather than some other – the reason that we have this particular health concept – is the advantages it conferred on groups of humans during our evolutionary history. My secondary property view sees health as a non-objective but non-evaluative property, and this places it in a previously unoccupied portion of the logical space created by distinguishing clearly between the dimensions of traditional disagreement.
The second part of the book concerns the attitude we should have towards medicine, and is informed by the understanding of the nature of medicine developed in the first part. Evidence Based Medicine and Medical Nihilism are discussed. The former sets high standards for what counts as evidence. The latter basically accepts these standards and then argues that so little medical research meets these standards that we should despair of medicine, and regard even apparently well-supported interventions as probably ineffective. Both views are rejected on their merits, but a connecting theme is their location of the whole value of medicine in its curative powers. I see value in medicine beyond cure, and thus even if the arguments of EBMers and nihilists succeeded on their merits (which I deny), they would not warrant such a negative attitude to the majority of medicine.
Philosophy of medicine has had little to say about non-Mainstream traditions, beyond occasional spats with alternative therapists. The last three chapters of the book seek to remedy this. A view called Medical Cosmopolitanism is advanced (inspired by Kwame Anthony Appiah’s book and ethical position Cosmopolitanism) as an alternative to the evidence-basing and nihilistic stances. The main tenets are realism about medical facts, especially what works, epistemic humility when discussing these facts, and the primacy of practice – focusing on specific problems rather than grand principles. Realism means that we should not shy away from trying to determine whether one or another intervention is better; we should not have a “hands off” approach, even where deep and/or cultural beliefs are at stake. Epistemic humility means that when approaching disagreements we must be mindful of the less-than-distinguished history of medical claims, and must be respectful, tentative, open to changing our mind. The primacy of practice is the idea that we focus first on what to do in particular cases, since agreement here is usually easier than on larger principles.
I then apply this position to medical dissidence and decolonization of medicine. Medical dissidence occurs when traditions co-exist with a more dominant tradition and reject parts of it. Homeopathy is the paradigm case. I advocate a much more tolerant stance between disputants about alternative medicine, arguing that the reason for different views (also extending to topics such as vaccination) is that all of our medical evidence reaches us through testimony, and trust then becomes king-maker as to which medical evidence you accept. It’s no good telling someone that a trial was fantastic if they just don’t believe you, and nor are they irrational to reject evidence from a trial if they just don’t believe that the trial occurred, or was fair, or similar. Unless you run a trial yourself, you are in the position of receiving your medical information second-hand, and then trust relationships become paramount. This patchy history of medical success amply explains why trust in any given tradition might be hard to come by.
Finally, contact between medicines deriving from different cultures presents interesting epistemic and practical challenges. In former colonies, these challenges must be handled carefully. Medicine is imbued with culture, and to insist on one medicine over another can be culturally oppressive. At the same time, cosmopolitanism is committed to realism. So, no matter how deeply held a belief in the efficacy of a certain intervention or ritual, if this ritual does not work or is less effective than one provided by Mainstream Medicine (as I call it – since it is no longer strictly Western) then this fact must be confronted. Moreover, ordinary people just want efficacy: we can quibble at the periphery, but fundamentally, illness is a universal human experience, as is holding a sick child in your arms. Thus I advocate something a little more critical than “dialogue” between traditions. I invite a critical attitude. The approach must be humble, and Mainstream Medicine must concede that it may well have something to learn from, e.g., African Medicine. But decolonization must fundamentally consist in the adoption of a critical mindset, one that rejected political colonization, and that goes on to reject epistemic colonization. This critical mindset demands that African, Chinese, Indian and other traditions take the inevitable confrontation with Mainstream Medicine seriously, and seriously consider whether their various interventions and strategies are effective, just as they ask Mainstream Medicine to take these interventions and strategies seriously.
My forthcoming book Philosophy of Medicine will be available 2 Jan 2019.
“The first thing to love about this book is what you can learn from it: what medicine can do even if it can’t cure much, what evidence-based medicine may have achieved and what it may not have, the role of common law and the importance of cosmopolitanism, the dangers of epistemic medical relativism, a value-free definition of ‘health’ and much more. The second is that it practices what it preaches. The epistemic humility and practice-centered cosmopolitanism that Broadbent advocates for medicine characterize his own arguments and explanations. The book is thoughtful, humane, informed, a serious study, both philosophically and practically.” – Nancy Cartwright, Professor of Philosophy at Durham University and Distinguished Professor at University of California, San Diego
“Alex Broadbent’s Philosophy of Medicine addresses important topics that have been largely eclipsed by debates on bioethics and the nature of health and disease. In particular, Broadbent focuses on the core issues of what medicine is essentially and how to make medical decisions. His book makes significant contributions to the field not only by addressing neglected topics with historical and cultural sensitivity, but also through some ground-breaking claims, for instance that the business of medicine is not to cure.” – Thaddeus Metz, Distinguished Professor of Philosophy, University of Johannesburg
Philosophy of Medicine asks two central questions about medicine: what is it, and what should we think of it? Philosophy of medicine itself has evolved in response to developments in the philosophy of science, especially with regard to epistemology, positioning it to make contributions that are medically useful. This book locates these developments within a larger framework, suggesting that much philosophical thinking about medicine contributes to answering one or both of these two guiding questions.
Taking stock of philosophy of medicine’s present place in the landscape and its potential to illuminate a wide range of areas, from public health to policy, Alex Broadbent introduces various key topics in the philosophy of medicine. The first part of the book argues for a novel view of the nature of medicine, arguing that medicine should be understood as an inquiry into the nature and causes of health and disease. Medicine excels at achieving understanding, but not at translating this understanding into cure, a frustration that has dogged the history of medicine and continues to the present day.
The second part of the book explores how we ought to consider medicine. Contemporary responses, such as evidence-based medicine and medical nihilism, tend to respond by fixing high standards of evidence. Broadbent rejects these approaches in favor of Medical Cosmopolitanism, or a rejection of epistemic relativism and pluralism about medicine that encourages conversations between medical traditions. From this standpoint, Broadbent opens the way to embracing alternative medicine.
An accessible and user-friendly guide, Philosophy of Medicine puts these different debates into perspective and identifies areas that demand further exploration.
Table of Contents
Part A. What Is Medicine?
1. Varieties of Medicine
2. The Goal of Medicine
3. The Business of Medicine
4. Health and Disease
Part B. What Should We Think of Medicine?
5. Evidence-Based Medicine
6. Medical Nihilism
7. Medical Cosmopolitanism
8. Alternatives and Medical Dissidence
9. Decolonizing Medicine
See more and pre-order at https://global.oup.com/academic/product/philosophy-of-medicine-9780190612139
My inaugural lecture, somewhat edited, has been published in the Journal of Medicine and Philosophy, along with relies by Thaddeus Metz and Chadwin Harris, and a rejoinder from me.
I’m proud of this, particularly because it’s the first time to my knowledge that this journal has published material on African medicine. It may even be the first publication in the contemporary philosophy of medicine, whether analytic or continental, that discusses African medicine in any meaningful way, or discusses Africa in a non-victim role (as opposed to discussions of unfair drug testing practices, neglected diseases, and so forth). I must emphasize that I stand to be corrected on each of these progressively more provocative speculations, and would be delighted for references which I will happily collate and list on another post.
The paper is about the nature of medicine and the role of cure, which I argue is not the main business of medicine, even if it’s the goal. My respondents, naturally, disagree.
Please let me know if you don’t have institutional access to the paper.