Preview: Abstract of Inaugural, ‘Prediction and Medicine’

Having blogged earlier today about philosophy, history and medicine, I’ve settled on an altered abstract for my upcoming inaugural. It’s below.

Anyone wanting an invite but who hasn’t received one by the end of this week should feel free to contact me directly and I’ll see if I can add you to the invite list. It’s 2 August.

 

Prediction and Medicine (Abstract)

What is medicine? In the context of the contemporary Western tradition, it is easy to suppose that medicine is the process of treating a sick person’s body, or mind, so as to make it better—or something like that, suitably adapted to take care of cosmetic surgery and so forth. But even so adapted, this “curative thesis” is not satisfactory. Historian of medicine Roy Porter maintains that the position of medicine in society has had, and still has, little to do with its ability to make people better. Perhaps Western medicine is uniquely capable at curing individuals given adequate resources, but it is very far from perfection even in these terms, as philosopher Jacob Stegenga has recently argued in urging “medical nihilism”. And its efficacy at improving population health has been famously doubted by historians and epidemiologists (hygiene, nutrition, wealth and peace being more effective). When we look at non-Western and older Western medicine, we see that Western medicine is unique in another way, in proffering explanations in terms of the individual body and, perhaps, mind. Most other traditions see disease as more widely significant, of sickness in the body politic (e.g. “the state of Denmark”), displeasure of ancestors of gods, malicious forces, imbalances in the natural order, and so forth. The “curative thesis” demands that we have mostly been stupid, duped, or staggeringly hopeful, given that medicine has not until recently and locally offered more than a handful of effective cures; and it ignores the connection of medicine with cosmic matters that is characteristic of most medicine. I suggest, in this lecture, that the core medical competence is not to cure, nor to prevent, but to predict disease. The predictions expected of doctors are both actual and counterfactual: both “When will I get better?” and “What would have happened if I had not taken my medicine?”. This “predictive thesis” does a better job than the “curative thesis” at explaining why not all medicine is concerned with curative efforts, and it enjoys considerable historical support from the ancient entanglement of prophesy 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, perhaps also enabling a fairer approach to alternative, traditional, and other medical practices. I also argue that it relieves medicine of the pretences of potency that generate the righteous indignation implicit in the arguments for medical nihilism. I also ask whether this descriptive thesis about the nature of medicine offers any prescriptions, or lessons, for the development of medicine.

Medicine, History, and Philosophy

On 2 August I’m delivering my inaugural at UJ. I’m developing the talk I gave at various places earlier in the year, so recycling the title (‘Prediction and Medicine’) and the abstract (below). If anyone can suggest an image for the publicity I would be very grateful–the obvious Google result of a doctor holding a crystal ball somehow does not appeal…

I’m currently trying to get my book on philosophy of medicine underway, and I’m increasingly convinced that the history of medicine must inform this discipline in a much more thorough way. Here are my initial broad brush thoughts.

First, it’s clear that the question “What is medicine?” is a really fruitful one. If you take a global view, of both time and place, you see many differences between practices, and some striking similarities. Roy Porter, my sole historical influence (and I realise I should diversify but he’s just so good), points out that most medical traditions see sickness and health, death and life as relating to humankind’s place in the cosmos. Hence the tendency to see disease as divine retribution, or the displeasure of ancestors, or malice on the part of evil spirits; and hence the connection–in Hamlet, for a European example–between sickness in the physical body and the body politic. (And, I suppose, the mind.) The modern Western tradition is unique in not seeing sickness in this way, but in understanding sickness by study of the sick body, more or less in isolation from its environment.

 

This provoked in me the thought that epidemiology is, in a way, the modern Western corollary of “our place in the universe” style explanations–that is, explanations in terms of influences, environment, and circumstance. This perhaps explains the tension that sometimes exists between medicine and epidemiology, between the biological perspective and the population perspective. Perhaps it also explains some of the tension between public health advocates, and their typical moral and political orientations, and the medical profession with their typical professional moral and political leanings.

Perhaps, even further, it shows Evidence Based Medicine in a new light. The suggestion that “bench science” should be at the bottom of the evidential hierarchy, and not leading the charge, is truly radical from a historical perspective, uniquely in the history of Western medicine. Western medicine is also uniquely successful among medical traditions, at least in its own terms: that is, measured in its the potential to cure individuals given adequate resources; the picture is far less clear if the measure is the actual improvement of population health, where, as epidemiologists have pointed out, other factors–nutrition, genetics, environmental exposures, income–have a larger effect than medical treatment per se. Nonetheless, Western medicine is uniquely successful on its own terms, and I wonder: is this attributable to the “anatomy first” approach? –and if so, does the EBM movement realise the enormity of recommending that this approach be, in effect, abandoned?

This is all massively general, of course: I did say “broad brush.”

The second thought that I can’t help be struck by, when reading history, is how much better historians are at speaking to non-historians than philosophers. I would love to be able to do this, because the questions I want my book to concern are questions many people care about and think about. Perhaps “What is medicine?” is too abstract, but sub-questions surely concern us: should I vaccinate my child? Has the doctor correctly diagnosed me? Should I take anti-depressants, see some sort of therapist, or just get out more? Am I sitting here waiting to be discharged for any good reason or is it just that it’s a Sunday and I could actually leave now? Do I drink too much, really (I know I’m above the guidelines but come on, they’re ridiculous)? What are the likely consequences of not breast feeding my child?

Philosophical discussion can help us answer these because of the gap created by conflicting medical advice. It’s not a matter of critiquing doctors; it is a matter of adjudicating between them, something that, in my experience, I have had to do almost every time we consult more than one doctor on the same matter. The fact is that there is considerable conflict in medical advice. Here is a recent example. A few days ago I took my youngest child for a round of vaccinations. The nurse said that if there was a fever later, we couldn’t give any paracetamol because the baby was too small, but should instead use a certain homeopathic suppository. This is a complete mix-up of supposedly contrary ideologies, and indeed of homeopathic method so far as I understand it. Moreover the nurse did not know that we had spent the previous week in hospital with the same little one (she had bronchiolitis) and during her stay she consumed considerable quantities of paracetamol. We accepted the suppositories, but haven’t used them (nor did we need to use paracetamol).

This is just one example; I’ve experienced numerous others, in fact in almost every matter of significance that I’ve had to consult a doctor on, with the possible exception of the removal of my appendix (and even that, according to a remark of a prominent EBMer at a conference shortly afterwards, could have been alternatively treated with high dose antibiotics according to the Best Evidence). This constant conflict between medical advice is at odds with what some commentators on medicine suggest–I mean those who are most shrill in their criticism of homeopaths, anti-vaccers, etc. (And I include EBM advocates, because they often seem to assume that the best evidence speaks for itself, with a single voice.) And that’s just within the Western medical tradition. It doesn’t begin to touch on how a young Zulu woman should direct herself when she hears voices and is told by her lecturer (me) to visit the university counselling service, and by her traditional healer that she is being called to that same profession.

All of this means that a good philosophical treatment of medicine that is accessible to people other than philosophers could be enormously useful. Bizarrely, philosophical academic writing is particularly tangled up in its own literature. It bristles with references. Historians can write papers about topics, in which the references to other historians are fairly select: the main interest is not (or need not be) what other historians have said about the topic, but the topic itself. Philosophers have trapped themselves into a new scholasticism: the interest of a topic for philosophers seems largely to lie in its relation to what other philosophers have, or have not, said about it. This is bizarre because philosophy is conceived by the non-philosopher as the dreamiest of disciplines, the most outward looking. But in its current form, it isn’t. Analytic philosophy is no better than continental in its obsession with its own texts; the difference is just that the texts analytics focus on are more recent. It is still possible to write a philosophical paper citing nothing but other philosophical papers; perhaps even desirable. I’m not saying that’s never ok, but if that is all we do, then how do we get off the ground? And more pressingly for my present topic, if that is what we are expected to do, then how can we ever write in a way that can be accessed and understood by the non-philosopher?

A lot has been made of access to the discipline in relation to class, wealth, race, gender. But aside from all those problems (and I do not belittle them), I think we have a deeper access problem. Far from being the kind of discipline that any intelligent person can engage in, with some though, we have a discipline that no outsider can meaningfully participate in or even learn much from without huge prior training, at which point they are no longer an outsider.

Broad brush, as I say… There are exceptions and qualifications, of course. Nonetheless I stand by my core claim, that philosophy has an unwarranted intellectual access problem, one that is not created by the intrinsic nature of the discipline but by the choices made among its professional practitioners about how to conduct debate and, indeed, what topics to discuss. But my hope is to break out of some of these difficulties, and I think that a book about medicine is a great opportunity to do it. Why can’t a philosophical treatment of medicine be as readable as Porter’s excellent historical treatment? I can’t think of a good answer.

How much of this I get to in the inaugural, I don’t know; the abstract for the latter is below. Perhaps I should change it and deliver a big picture discussion of the nature of philosophy… But I’m not sure I’m quite brave enough for that yet.

 

Abstract

Historian of medicine Roy Porter maintains that the position of medicine in society has had, and still has, little to do with its ability to make people better. There is a line of thinking in both history and philosophy of medicine that we might call medical nihilism (following Jacob Stegenga). This view holds that medicine is not what it is cracked up to be. But this view assumes (unlike Porter) that the purpose of medicine is indeed to cure people. In this paper I argue that the core medical competence is not to cure, nor to prevent, but to predict disease. The predictions expected of doctors are both actual and counterfactual: both “When will I get better?” and “What would have happened if I had not taken my medicine?”. This “predictive thesis” does a better job than the “curative thesis” at explaining why not all medicine is concerned with curative efforts, and it enjoys considerable historical support from the ancient entanglement of prophesy and medicine and from the fact that medicine thrived for centuries with almost no effective cures, and continues to thrive today in various non-Western and complimentary forms that are mostly without curative efficacy. I also argue that it relieves medicine of the pretences of potency that generate the anger implicit in the arguments for medical nihilism. This view also affects expectations of epidemiology, which is sometimes criticised for cataloguing predictive risk factors whose causal relation to the outcome is unclear, instead of identifying decisive interventions. Finally I ask whether this descriptive thesis about the nature of medicine offers any normative lessons for the development of medicine.

Epidemiology and Law: two publications

Recently published:

Forensic Epidemiology, Principles and Practice. 2016. Freeman M and Zeegers M (eds). Eslevier. http://store.elsevier.com/Forensic-Epidemiology/isbn-9780124046443/

(I have a paper on causation and epidemiology.)

Also, previously online but now in print:

‘Tobacco and Epidemiology in Korea: old tricks, new answers?’ Broadbent A and Hwang Ss. Journal of Epidemiology and Community Health 2016;70:527-528. http://jech.bmj.com/content/70/6/527.full doi:10.1136/jech-2015-206567 [open access]

Miscarriage, economic downturns and causality

There is a really interesting piece and ensuing discussion in recent American Journal of Epidemiology:

“Spontaneous Pregnancy Loss in Denmark Following Economic Downturns” http://aje.oxfordjournals.org/content/183/8/701.full?etoc

I find this interesting for a lot of reasons, including that it suggests another respect in which health and economic well-being are linked. But I am particularly curious how potential outcomes enthusiasts would respond to this sort of study, given that an economic downturn is neither a well-defined intervention nor susceptible to one.

Potential Outcomes at the LSHTM

Along with my co-authors Jan Vandenbroucke and Neil Pearce, I engaged in a stimulating debate at the London School of Hygiene and Tropical Medicine today, on this paper:

http://ije.oxfordjournals.org/content/early/2016/01/21/ije.dyv341.full.pdf

Here is a link to the slides from my presentation:

https://www.dropbox.com/s/n0xe0zz86gyfxo4/2016-03-07%20Causal%20Inference%20in%20Epidemiology.pptx?dl=0

The debate was impassioned yet civilized. For me the most striking thing was how much seemed to come down to who said what, and who thought what. Are we attacking a straw man? If so, does that mean we’re right in substance, and wrong to think anyone would disagree? That itself would be remarkable, because it really seems to me, both from reading and talking, including feedback from other audiences, that some people do espouse the views we criticize. Or if we are not attacking a straw man, then is our position correct, or a sort of methodolical Ludditism, a reactionary preference for existing views?

I hope that more epidemiologists, and hopefully philosophers too, will weigh in.

March talks in UK and Norway

I’m giving several talks over the next two weeks in the UK, and one in Bergen, Norway. I’m also having a book launch and giving a career advice session. Schedule as follows and abstracts below.

2 March, 1-2.30pm. Cambridge Philosophy of Science Forum: ‘Prediction and Medicine’ (abstract below).

4 March, 1.30-3pm. Masterclass/Reading Group for MSc/PhD students, UCL, on two recent papers: ‘Causation and Prediction in Epidemiology: A Guide to the Methodological Revolution’ (Studies in History and Philosophy of Biological and Biomedical Sciences 2015) and ‘Causality and causal inference in epidemiology: the need for a pluralistic approach’ (with Jan Vandenbroucke and Neil Pearce, International Journal of Epidemiology 2016)

4 March, 3-5pm. UCL STS Seminar: ‘Prediction and Medicine.’

4 March, 5.30-8pm. Book launch of “Philosophy for Graduate Students: Metaphysics and Epistemology’ (Routledge 2016) and career advice session (abstract below).

7 March, 12.30-2pm. London School of Hygiene and Tropical Medicine seminar, with Jan Vandenbroucke and Neil Pearce. ‘Causal Inference in Epidemiology: What Was It, What Is It, and What Will It Become?’ (Abstract below.)

8 March, 3-5pm. Bergen philosophy seminar: ‘Prediction and Medicine.’ (Abstract below.)

9 March, 4-5.30pm. Oxford philosophy of medicine seminar: ‘Prediction and Medicine.’ (Abstract below.)
Abstract: Prediction and Medicine

Historian of medicine Roy Porter maintains that the position of medicine in society has had, and still has, little to do with its ability to make people better. There is a line of thinking in both history and philosophy of medicine that we might call medical nihilism (following Jacob Stegenga). This view holds that medicine is not what it is cracked up to be. But this view assumes (unlike Porter) that the purpose of medicine is indeed to cure people. In this paper I argue that the core medical competence is not to cure, nor to prevent, but to predict disease. The predictions expected of doctors are both actual and counterfactual: both “When will I get better?” and “What would have happened if I had not taken my medicine?”. This “predictive thesis” does a better job than the “curative thesis” at explaining why not all medicine is concerned with curative efforts, and it enjoys considerable historical support from the ancient entanglement of prophesy and medicine and from the fact that medicine thrived for centuries with almost no effective cures, and continues to thrive today in various non-Western and complimentary forms that are mostly without curative efficacy. I also argue that it relieves medicine of the pretences of potency that generate the anger implicit in the arguments for medical nihilism. This view also affects expectations of epidemiology, which is sometimes criticised for cataloguing predictive risk factors whose causal relation to the outcome is unclear, instead of identifying decisive interventions. Finally I ask whether this descriptive thesis about the nature of medicine offers any normative lessons for the development of medicine.


Abstract: Career Advice Session at UCL on 4 March

Gloom and doom dominate current discussions about the state of higher education, and humanities in particular. In this climate, why would anyone wanting to be able to feed themselves and their family embark on an academic career, and in particular a career in philosophy, which is especially arduous and especially abstract? More practically, if you find yourself in this track, are there things you can do to improve your chances of success? The answer to the latter is a definite “yes”, but because the shape of the academic profession is changing, some of the philosophical standard career advice that would have worked even a few years ago is no longer applicable. Alex Broadbent is a young philosopher of science and also Dean of Humanities at the University of Johannesburg. He is committed to the view that philosophy can be useful without compromising rigour, and also to the view that academics – especially young ones – need to be more proactive about running their universities. He is author of “Philosophy of Graduate Students: Metaphysics and Epistemology” recently published by Routledge. In this session he offers some ideas about managing an early career in the contemporary academic world.
Abstract: Causal Inference in Epidemiology: What Was It, What Is It, and What Will It Become?

Epidemiology is centrally concerned with identifying causes of health and disease, so as to inform the search for effective interventions, either in public health policy or in the clinic. The epidemiology of the second half of the twentieth century saw the connection between a cause of disease and an effective intervention as a very loose one, with the intervention to be uncovered later after further biomedical research. By contrast, the first part of this century has witnessed a strong push to connect the notions of cause and intervention. This movement, often going under the misleadingly broad label “causal inference”, sees a very tight connection between interventions and causes, such that a causal question is not even well defined for the purposes of epidemiological research unless there is a well-specified intervention on that cause, against which the causal effect is measured. This movement is inspired in part by a pragmatic concern with achieving effective interventions and in part by the appeal of the powerful mathematical tools that can be used if causal questions are restricted in this way. It is the development and deployment of these tools that various recent workshops books on “causality” (Pearl 2009) and “causal inference” (Hernán and Robins 2015) focus upon. This technical focus hides the revolutionary nature of this new way of thinking about causality and causal inference. This workshop seeks to understand the conceptual framework of this movement, to place it in context against traditional epidemiological thinking, and to establish both the advantages and the risks of accompanying this “methodological revolution”.

This event has been organised as part of the Design and Analysis theme of the Centre for Evaluation. The event is intended for staff and students interested in evaluation, casual inference, and epidemiology.

Paper: Causality and Causal Inference in Epidemiology: the Need for a Pluralistic Approach

Delighted to announce the online publication of this paper in International Journal of Epidemiology, with Jan Vandenbroucke and Neil Pearce: ‘Causality and Causal Inference in Epidemiology: the Need for a Pluralistic Approach

This paper has already generated some controversy and I’m really looking forward to talking about it with my co-authors at the London School of Hygiene and Tropical Medicine on 7 March. (I’ll also be giving some solo talks while in the UK, at Cambridge, UCL, and Oxford, as well as one in Bergen, Norway.)

The paper is on the same topic as a single-authored paper of mine published late 2015, ‘Causation and Prediction in Epidemiology: a Guide to the Methodological Revolution.‘ But it is much shorter, and nonetheless manages to add a lot that was not present in my sole-authored paper – notably a methodological dimension that, as a philosopher by training, I was ignorant. The co-authoring process was thus really rich and interesting for me.

It also makes me think that philosophy papers should be shorter… Do we really need the first 2500 words summarising the current debate etc? I wonder if a more compressed style might actually stimulate more thinking, even if the resulting papers are less argumentatively airtight. One might wonder how often the airtight ideal is achieved even with traditional length paper… Who was it who said that in philosophy, it’s all over by the end of the first page?