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.

What should I call my book?

I’m spending July finalising my manuscript for a book that was to be called Philosophy of Medicine which is under contract with Oxford University Press. However, Routledge has this year published Philosophy of Medicine: An Introduction by the excellent Thompson and Upshur. Do I change my title, or not?

The contents are quite different as you can see by comparing the ToC of that book and the (latest) ToC of my own, below (on which comments are very welcome of course).

My book ends up defending a position that I call Medical Cosmopolitanism, and I could use this as the title, perhaps with a subtitle like “What is medicine and what should we think of it?” or something. But I worry that Medical Cosmopolitanism is going to be confusing.

Any thoughts and ideas are welcome!

My latest ToC:

About this Book

Introduction

Ch 1: What Is Philosophy of Medicine?

Ch 2: Medical Traditions

Ch 3: The Point of Medicine

Ch 4: What Are Doctors Good At?

Ch 5: Evidence-Based Medicine

Ch 6: Person and Medicine

Ch 7: Medical Nihilism

Ch 8: Alternatives and Medical Dissidence

Ch 9: Decolonizing Medicine

Ch 10: Health and Disease

Ch 11: Medical Cosmopolitanism

Call for Papers: Philosophy of Epidemiology, a Special Issue of Synthese

 

Guest Editors: Sean A. Valles (Michigan State University, USA) and Jonathan Kaplan (Oregon State University, USA)

Special Issue Description: Philosophy of epidemiology is a burgeoning subfield within the philosophy of science and medicine. This special issue will provide philosophy of epidemiology with a forum to develop this area and expand its boundaries. The guest editors seek both to help develop philosophy of epidemiology’s existing lines of research (e.g., models of causal analysis) and expand philosophy of epidemiology to include a broader community of contributors (e.g., philosophers of race) and a wider array of lines of research (e.g., concepts of epidemiological risk and human-ecosystem dynamics).

Appropriate topics for submission include, but are not limited to: the role(s) of values in epidemiology; the role(s) of formal models in epidemiology; concepts of risk in epidemiology; the relationship between philosophy of epidemiology and philosophy of ecology (and other branches of philosophy); the metaphysical and causal repercussions of epidemiological data on the environmental and social determinants of health.

For further information, please contact the guest editors:

  • valles@msu.edu
  • kaplanj@oregonstate.edu

Deadline for submissions is: October 9, 2017

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.