Synopsis of my book

Further to previous post, here is a synopsis of the book, with a slightly different structure from the previous ToC, but largely the same. I am considering removing the first chapter, “What Is Philosophy of Medicine?”, on account of it being a bit boring for non-philosophers. I can do what I need to by way of setting up methodologies in the introductory material.

Any thoughts on whether the book described below fits the title “Philosophy of Medicine”, or something else (“Medical Cosmpolitanism”?), would be appreciated.

Synopsis

The book sets out to answer two questions: “What is medicine?” and “What attitude should we adopt towards it?” The answer to the first question informs the answer to the second. Through answering these two questions, the book provides a unifying vision of the field that is at once useful for someone looking for a way into the field and novel enough to interest the expert.

Chapter 1, The Variety of Medicine, surveys historical and contemporary medicine in various locations around the world, emphasizing the differences between traditions and the extent to which traditions change. This enormous variety means that an empirical survey alone is not enough to tell us what medicine is.

Chapter 2, What Is Medicine?, sets out two broad answers to the title question. The first is the Curative Thesis, which says that medicine is fundamentally the sustained and organized effort to heal the sick and promote health, without specifying anything about the means employed, and thus about the character of medical activity. The second is the Inquiry Thesis, which agrees that medicine’s goal is healing the sick, but says that its core business understanding and predicting health and disease. Cure is a central goal on both views. The main difference between them is that on the Inquiry Thesis, medicine can partially succeed even when it cannot cure, while according to the Curative Thesis, curative failure is complete failure for medicine.

Chapter 3, What Are Doctors Good At?, argues against the Curative Thesis and in favour of the Inquiry Thesis, to the effect that medicine is not generally very impressive at curing, but that it has much more success at the core business of understanding and predicting health and disease. If a doctor fails to cure you, you do not necessarily blame the doctor; you may blame the disease. However, if a doctor clearly does not understand what is going on, you will no longer regard them as an expert in the relevant medical field.

Chapter 4, Evidence-Based Medicine, argues that EBM arises from a commitment to the Curative Thesis, elevating effectiveness of interventions as the sole measure of medical success. The chapter argues that this approach to medicine is both unworkable and unwarranted. Much of the warrant for medical interventions arises from theoretical knowledge and not from direct clinical testing. This is both inescapable in practice and defensible in theory.

Chapter 5, Person and Medicine, considers the suggestion that has re-emerged recently in reaction to EBM that Mainstream Medicine is too general, and that the “person” or “patient” needs to be more central. The suggestion does not yield any obvious solutions to the puzzle of ineffective medicine—it does not promise to make medicine strikingly more effective.

Chapter 6, Medical Nihilism, considers the position that takes the bull by the horns, and concludes from the puzzle of ineffective medicine that we should generally have low confidence in any given medical intervention. Nihilism is rejected in this chapter on the grounds that only Therapeutic Nihilism is warranted by this argument, and only an endorsement of the Curative Thesis could support the identification of Therapeutic Nihilism with Medical Nihilism. Once this distinction is made, Therapeutic Nihilism can also be rejected, since (like EBM) it ignores much of the important warrant for medical interventions, which lies in the theoretical knowledge underpinning them and not in the results of testing.

Chapter 7, Alternatives and Medical Dissidence, considers the phenomenon of alternative medicine, which is characterized by the explicit rejection of parts or the whole a Mainstream tradition in favour of something else, or, alternatively, the belief that Mainstream Medicine leaves something out and can be “complemented” by other practices. The chapter argues that the enormous reliance on expert testimony in any medical encounter precludes the excessively strong moral and intellectual judgements that are sometimes made of both patients and practitioners. Further, the chapter argues that part of the motivation for seeking alternative medicine is to find answers to questions that are not answerable within the Mainstream tradition. This is discordant with the Curative Thesis, and fits with the idea that medicine provides more than just cures: it is also expected to yield understanding.

Chapter 8, Decolonizing Medicine, considers the relation between different medical traditions in parts of the world where contemporary Mainstream Medicine is part of a colonial heritage. The chapter argues that it is even less acceptable in this situation to visit very general harsh judgements on practitioners and patients of non-Mainstream traditions. However, the chapter argues that relativism about medicine is fundamentally implausible, because the suffering of sickness is a universal human experience. The notion of Medical Cosmopolitanism is introduced, as an epistemic attitude that is humble and respectful, but not pluralistic, and thus which seeks to enter into conversation and resolve differences rather than simple permit them to continue. The conclusion, ironically, is that medical traditions will tend to merge, and so “medically decolonizing” a region is neither desirable nor likely; but that for this to happen fruitfully and fairly, the cosmopolitan attitude must be adopted, with a view to humbly but critically assessing and resolving differences.

Chapter 9, Health and Disease, considers the subject matter of medicine, which must also be understood if we are to understand the nature of medicine and arrive at a reasonable attitude towards it. Health is identified as a secondary property, which is a property that exists neither wholly independent of being perceived, nor depends wholly on being perceived. The classic example is colour, which depends both on things that do not depend on us at all (such as light of certain wavelenghts striking the eye) and on our dispositions to react in certain ways to these independent events (such as the construction of our eyes and visual systems). Health is a dispositional property depending on the way we react to certain biological states, and the particular content that the health concept has is explained by the evolutionary advantage that having this concept confers. Particular diseases are departures from health for which some general explanation can be found. These notions are compatible with cultural variation in what counts as healthy and diseased (unlike the “naturalist” accounts) but anticipate much overlap, and explain why diseases are usually considered misfortunes (unlike “normativist” accounts).

Chapter 10, Medical Cosmopolitanism, puts it all together. It argues that medicine is best understood as an inquiry with a purpose (as the Inquiry Thesis has it) rather than as the mere pursuit of a goal by whatever means (as the Curative Thesis has it). It argues that this best explains the puzzle of ineffective medicine. It further argues that the status of medicine as an inquiry justifies a cosmopolitan attitude towards it. The value of a medical tradition does not lie solely in its curative success, so it neither wise not just to simply write of curatively unsuccessful traditions.

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