1. Lying -- 2. The problem of what is said -- 3. What is said -- 4. Is lying worse than merely misleading? -- 5. Some interesting cases.

Medical nihilism is the view that we should have little confidence in the effectiveness of medical interventions. Jacob Stegenga argues persuasively that this is how we should see modern medicine, and suggests that medical research must be modified, clinical practice should be less aggressive, and regulatory standards should be enhanced.

Harms of medical interventions are systematically underestimated in clinical research. Numerous factors—conceptual, methodological, and social—contribute to this underestimation. I articulate the depth of such underestimation by describing these factors at the various stages of clinical research. Before any evidence is gathered, the ways harms are operationalized in clinical research contributes to their underestimation. Medical interventions are first tested in phase 1 ‘first in human’ trials, but evidence from these trials is rarely published, despite the fact that such trials provide the (...) foundation for assessing the harm profile of medical interventions. If a medical intervention is deemed safe in a phase 1 trial, it is tested in larger phase 2 and 3 clinical trials. One way to think about the problem of underestimating harms is in terms of the statistical ‘power’ of a clinical trial—the ability of a trial to detect a difference of a certain effect size between the experimental group and the control group. Power is normally thought to be pertinent to detecting benefits of medical interventions. It is important, though, to distinguish between the ability of a trial to detect benefits and the ability of a trial to detect harms. I refer to the former as power-B and the latter as power-H. I identify several factors that maximize power-B by sacrificing powerH in phase 3 clinical trials. If a medical intervention is approved for general use, it is evaluated by phase 4 post-market surveillance. Phase 4 surveillance of harms further contributes to underestimating the harm profile of medical interventions. At every stage of clinical research the hunt for harms is shrouded in secrecy, which further contributes to the underestimation of the harm profiles of medical interventions. (shrink)

It is one of the central aims of the philosophy of science to elucidate the meanings of scientific terms and also to think critically about their application. The focus of this essay is the scientific term predict and whether there is credible evidence that animal models, especially in toxicology and pathophysiology, can be used to predict human outcomes. Whether animals can be used to predict human response to drugs and other chemicals is apparently a contentious issue. However, when one empirically (...) analyzes animal models using scientific tools they fall far short of being able to predict human responses. This is not surprising considering what we have learned from fields such evolutionary and developmental biology, gene regulation and expression, epigenetics, complexity theory, and comparative genomics. (shrink)

Proposals for regulating or nudging healthy choices are controversial. Opponents often argue that individuals should take responsibility for their own health, rather than be paternalistically manipulated for their own good. In this paper, I argue that people can take responsibility for their own health only if they satisfy certain epistemic conditions, but we live in an epistemic environment in which these conditions are not satisfied. Satisfying the epistemic conditions for taking responsibility, I argue, requires regulation of this environment. I describe (...) some proposals for such regulation and show that we cannot reject all regulation in the name of individual responsibility. We must either regulate individuals’ healthy choices or regulate the epistemic environment. (shrink)

There is a robust scientific consensus concerning climate change and evolution. But many people reject these expert views, in favour of beliefs that are strongly at variance with the evidence. It is tempting to try to explain these beliefs by reference to ignorance or irrationality, but those who reject the expert view seem often to be no worse informed or any less rational than the majority of those who accept it. It is also tempting to try to explain these beliefs (...) by reference to epistemic overconfidence. However, this kind of overconfidence is apparently ubiquitous, so by itself it cannot explain the difference between those who accept and those who reject expert views. Instead, I will suggest that the difference is in important part explained by differential patterns of epistemic deference, and these patterns, in turn, are explained by the cues that we use to filter testimony. We rely on cues of benevolence and competence to distinguish reliable from unreliable testifiers, but when debates become deeply politicized, asserting a claim may itself constitute signalling lack of reliability. (shrink)

Published research findings are sometimes refuted by subsequent evidence, says Ioannidis, with ensuing confusion and disappointment.

Industry is a major source of funding for scientific research. There is also a growing concern for how it corrupts researchers faced with conflicts of interest. As such, the debate has focused on whether researchers have maintained their integrity. In this article we draw on both the history of medicine and formal modeling to argue that given methodological diversity and a merit-based system, industry funding can bias a community without corrupting any particular individual. We close by considering a policy solution (...) that may seem to promote unbiased inquiry but that actually exacerbates the problem without additional restrictions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ideal of Shared Decision Making Between Physicians and PatientsDan W. Brock (bio)IntroductionShared treatment decision making, with its division of labor between physician and patient, is a common ideal in medical ethics for the physician-patient relationship.1 Most simply put, the physician's role is to use his or her training, knowledge, and experience to provide the patient with facts about the diagnosis and about the prognoses without treatment and with (...) alternative treatments. The patient's role in this division of labor is to provide the values—his or her own conception of the good—with which to evaluate these alternatives, and to select the one that is best for himself or herself. As a rough guide to practice, this is a reasonable conception; most of the time it is likely to produce sound treatment decisions. However, as an ideal it is too simplistic, and is subject to several challenges that I will explore in this paper.Some challenges relate to the physician's role. This facts/values division of labor seems to assume that the physician can and should provide the facts about treatment alternatives in a value-neutral form. But some have questioned whether the sciences on which medicine is based are, or can be, value free. Moreover, the concepts of health and disease, and of the normal and pathological, are held by many to be value laden. And even if it is possible for physicians to provide only value-neutral facts to the patient, should the physicians' role be restricted in this way?Other challenges that I will present in the paper are to the patient's role [End Page 28] as provider of the values for the evaluation of the different treatment alternatives. One defense of this role is based on the claim that physicians are not in a position to know reliably what is in a patient's best interests (Buchanan, forthcoming). I believe at least as influential—even if often not explicitly stated—is an extreme subjectivism about values that assumes that the patient's own ultimate values, which define his or her own conception of the good, are incorrigible. By incorrigible, I mean they cannot be mistaken. In the standard case in which treatment is pursued for the patient's benefit, this extreme subjectivism is thought to support the patient's values guiding treatment decision making and treatment. I will explore this incorrigibility claim and will argue that on each of the main philosophical conceptions of the good for persons it is indefensible and should not be the basis for shared treatment decision making.Underlying this view of the physician-patient division of labor are assumptions and beliefs about the nature and relation of facts and values, and science and ethics, that are largely the legacy of a logical positivism that has long since been rejected by most philosophers. It is time that these unstable foundations for our normative ideal of the physician-patient relation were finally removed and replaced with more defensible underpinnings.Two Models of the Physician-Patient RelationshipPositivists insisted on a relatively sharp distinction between descriptive or empirical claims and science, on the one hand, and evaluative claims and ethics, on the other.2 Descriptive statements and the claims of science were to be true or false according to whether they in fact correctly described and explained the world. By remaining properly descriptive or empirical, science could, at least in principle, be entirely value neutral or value free.In its more extreme versions, positivism held that ethical judgments lacked cognitive content, but were instead expressions of emotions or attitudes, and as such could be neither true nor false, correct or mistaken. Because no evaluative statements were held to be logically entailed by any descriptive or empirical statements, moral reasoning was thought to be properly understood not as reasoning but as attempts at nonrational persuasion.3 Many drew from this an extreme subjectivism in ethics along the lines of what I have called above the incorrigibility thesis—there is no meaningful sense in which an individual's ultimate values defining his or her own conception of the good life could be mistaken, false, or unfounded.These... (shrink)

Uncertainty is an inherent part of knowledge, and yet in an era of contested expertise, many shy away from openly communicating their uncertainty about what they know, fearful of their audience’s reaction. But what effect does communication of such epistemic uncertainty have? Empirical research is widely scattered across many disciplines. This interdisciplinary review structures and summarises current practice and research across domains, combining a statistical and psychological perspective. This informs a framework for uncertainty communication in which we identify three objects (...) of uncertainty -facts, numbers, and science-and two levels of uncertainty: direct and indirect. An examination of current practices provides a scale of nine expressions of direct uncertainty. We discuss attempts to codify indirect uncertainty in terms of quality of the underlying evidence. We review the limited literature about the effects of communicating epistemic uncertainty on cognition, affect, trust, and decision-making. While there is some evidence that communicating epistemic uncertainty does not necessarily affect audiences negatively, impact can vary between individuals and communication formats. Case studies in economic statistics and climate change illustrate our framework in action. We conclude with advice to guide both communicators and future researchers in this important but so far rather neglected field. (shrink)

The book concludes with a qualified defence of the view that honesty is a virtue.

For evidence-based practice and policy, randomised controlled trials (RCTs) are the current gold standard. But exactly why? We know that RCTs do not, without a series of strong assumptions, warrant predictions about what happens in practice. But just what are these assumptions? I maintain that, from a philosophical stance, answers to both questions are obscured because we don't attend to what causal claims say. Causal claims entering evidence-based medicine at different points say different things and, I would suggest, failure to (...) attend to these differences makes much current guidance about evidence for medical and social policy misleading. (shrink)

Scientists and their supporters often portray as exasperatingly irrational all those laypersons who refuse to accede to practical recommendations issued by expert scientists and 'science appliers'. After first considering the latter groups’ standard explanations for such non-deference, which focus upon irrationalities besetting the laity, I will propose that a better explanation for at least some of the non-deference is that many laypersons are rationally electing to substitute their own judgments for those urged upon them by the scientific community. Science-based recommendations, (...) as I treat them, have the general form In light of the science on X, if you seek outcome O, you ought to V. Non-deferring laypersons deny the soundness or cogency of the V-supporting argumentation—though they are supposedly not competent to do so, given their gross epistemic inferiority to the scientific authorities who create and endorse the arguments. On account of thus being epistemically irrational, they end up being instrumentally irrational, pursuing courses of action that are poor choices for serving their own interests. The non-deferring laypersons are thought to violate two mandates of rationality: for internal deference to the underlying science as true enough to constitute an unproblematic background for decisionmaking, and for external deference to the practical application of that science to the concrete extra-scientific circumstances in question. I claim that rationality does not require categorical adherence to these mandates. In any given case, non-deference by some laypersons might be warranted by one or more of four distinct rationales. 1. Value-ladenness: The science-based recommendation discernibly includes non-scientific value-choice or value-weighting assumptions. It embodies a certain prioritizing of the plurality of specific values packed within its O parameter, and some laypersons may permissibly substitute their own. 2. Non-scientific-reasoning-ladenness: The science-based recommendation discernibly relies upon reasoning moves that are not distinctive to science, moves whose critical assessment demands no scientific expertise. Error-free reasoning is difficult to attain, and the laypersons may justifiably take themselves to have found weaknesses in the V-supporting argumentation that undermine the case for conformity to the recommendation. 3. Overgeneralization: The science-based recommendation discernibly is not adequately tailored to the specific situation of the laypersons in question. 4. Untrustworthy science: The science-based recommendation discernibly is based upon scientific research that is of doubtful quality. The first three rationales cast doubt upon the External Deference Mandate, questioning not the existence of sound underlying research but the recommendation’s judgments about how this research ought to be applied. The fourth is a challenge to the Internal Deference Mandate. (shrink)