Chapter 1 Who this book is for and who it is not for1 There are already too many books offering solutions to the problems of the health service. ...

Editors' introduction to 3rd thematic issue on philosophy of medicine.

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

The success of medicine in the treatment of patients brings with it new challenges. More people live on to suffer from functional, chronic or multifactorial diseases, and this has led to calls for more complex analyses of the causal determinants of health and illness. Philosophical analysis of background assumptions of the current paradigmatic model. While these factors do not require a radical paradigm shift, they do give us cause to develop a new narrative, to add to existing narratives that frame (...) our thinking about medical care. In this paper we argue that the increased focus on lifestyle and shared decision making requires a new narrative of agency, to supplement the narrative of “the patient”. This narrative is conceptually linked to the developing philosophy of person-centred care. If patients are seen also as “agents” this will result in a substantial shift in practical decisions: The development and adoption of this narrative will help practitioners work with patients to their mutual benefit, harnessing the patients’ motivation, shifting the focus from treatment to prevention and preventing unnecessary and harmful treatments that can come out of our preoccupation with the patient narrative. It will also help to shift research efforts, conceptual and empirical, from “treating” and “battling” diseases and their purported “mechanisms” to understanding complex contributing factors and their interplay. (shrink)

Moss is right to state that management theory needs to address its epistemological foundations by considering questions in epistemology and the philosophy of science. Whether management theory needs Popper is a more tricky question. It is not clear that all theories should be falsifiable in Popper’s terms. His proposed methodology for social scientific research is inherently conservative and threatens to inhibit intellectual and social progress. But Popper’s philosophical realism and rationalism need to be preserved. Coherentism and associated forms of anti-rationalism (...) (including postmodernism and relativism) threaten to provide a rationale for the worst excesses of management theory. Indeed, the poverty of contemporary management theory is a symptom of a broader intellectual malaise: debate is increasingly characterised by the exchange of persuasive rhetoric, making it difficult to hold those in positions of power accountable for rationally justifying the positions they espouse. (shrink)

Contributors to the debate on ethical rationing bring with them assumptions about the proper role of moral theories in practical discourse, which seem reasonable, realistic and pragmatic. These assumptions function to define the remit of bioethical discourse and to determine conceptions of proper methodology and causal reasoning in the area. However well intentioned, the desire to be realistic in this sense may lead us to judge the adequacy of a theory precisely with reference to its ability to deliver apparently determinate (...) answers to questions that strike most practitioners and patients as morally arbitrary. By providing ethical solutions that work given the world as it is, work in clinical ethics may serve to endorse or protect from scrutiny the very structures that need to change if real moral progress is to be possible. Such work can help to foster the illusion that fundamentally arbitrary decisions are ‘grounded’ in objective, impartial reasoning, bestowing academic credibility on policies and processes, making it subsequently harder for others to criticise those processes. As theorists, we need to reflect on our political role and how best to foster virtuous, critical practice, if we are to avoid making contributions to the debate that not only do no good, but may even be harmful. A recent debate in this journal illustrates these issues effectively. (shrink)

To someone coming fairly fresh to this debate, Sykes’ paper is somewhat shocking. The psychogenic inference seems such an obvious fallacy, yet he shows, with detailed reference to both diagnostic practice and the literature on mental disorders, the extraordinary pervasiveness of its influence, extending even to the systematic ambiguities built into key diagnostic terms. Sykes characterizes the inference in the following terms: “If there is no known physical cause for a symptom or disorder, the cause must be psychological” (2010, 290). (...) He notes the glaring fallacy of mistaking an epistemological point (that a physical cause is not, at present, known) for an ontological one (that no such cause exists) and .. (shrink)

This paper provides a commentary on “Vascular amputees: A study in disappointment” and its significance in the development of the disability rights movement, as well as the movements for values-based medicine and person-centred health and social care.

Philosophy of medicine encompasses a broad range of methodological approaches and theoretical perspectives—from the uses of statistical reasoning and probability theory in epidemiology and evidence-based medicine to questions about how to recognize the uniqueness of individual patients in medical humanities, person-centered care, and values-based practice; and from debates about causal ontology to questions of how to cultivate epistemic and moral virtue in practice. Apart from being different ways of thinking about medical practices, do these different philosophical approaches have anything in (...) common? Are they committed to incompatible assumptions about the nature of science and its relationship to experience, value, and the art of medicine, or are different approaches nonetheless complementary? The chapter examines the questions these different approaches and perspectives raise and considers why so many theorists of medicine seek to find a “base” or “center” for medicine—as though there is, or should be, some general conceptual thread linking the things we call “usual clinical practice” in the real world. It further considers whether there are alternative approaches to the philosophy of medicine, which do not embody this philosophical assumption; and it suggests that a key tool for evaluating approaches must be their ability to contribute something of genuine value to clinical medicine. (shrink)

Professor Spicker's two-pronged attack on welfare seems to presuppose the Kantian distinction between morality and prudence. His prudential critique rests on a massively oversimplified and somewhat offensive view of the causes of poverty. His moral premise is unsupported, and inconsistent with his demand for a state-funded investment in education. His article provides an excellent illustration of the anti-realist and Utopian nature of the ideology of the new right.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.3 (2003) 261-264 [Access article in PDF] Contingency, Arbitrariness, and Failure Michael Loughlin PICKERING AIMS TO affect the form of the debate about the reality of mental illness. He notices that many influential arguments both for and against the existence of mental illnesses are in an important sense circular. It is observed that a given condition is relevantly similar to conditions we all agree are (...) genuine illnesses and on the basis of this observation it is concluded that it too can be classified as a type of illness—from which it can be inferred that mental illnesses do indeed exist. But Pickering contends that the initial observation can only be made if we already construe the condition in question as a type of illness. Otherwise we may interpret the data differently.So unless we help ourselves to the categorization whose legitimacy it is supposed to establish, the likeness argument cannot get going. He illustrates his point effectively. Most of his examples are taken from authors defending the existence of mental illness and it would have been interesting to see a more detailed account of the argument working in the other direction. Even so, his references to Szasz (Pickering 2003) are sufficient to convince readers familiar with Szasz's work that a version of the likeness argument (the paradigm approach) is as much at work in his refutation of the existence of mental illnesses as is it in Boorse's proof of their reality.This is an incisive analysis, which should be taken very seriously indeed by contributors to the debate. Its most immediate implication is a negative one. We should not rely upon any version of the likeness argument to establish the existence (or nonexistence) of mental illnesses: "the likeness argument must fail" (Pickering 2003, p. 253). One important question left unanswered by the paper concerns what form the debate should take, if its criticisms are accepted. Assuming we agree that the likeness argument is methodologically flawed, what should the methodology be for debating the substantive issues at stake? Put another way, how can we break the circle? How is it possible to construct arguments that do not presuppose their main conclusions, and so to make real intellectual progress in addressing this issue? Is this in fact possible? What would a valid argument in this area look like, and what sort of observational premises (if any) would be acceptable as evidence?On the most skeptical reading of his thesis, Pickering's arguments render the ideal of intellectual progress toward a resolution of this debate strictly unattainable. The circle cannot be broken, because the theory dependence of our categorizations makes the truth about the reality of mental illness either unknowable or irredeemably relative to one's intellectual starting point. Having argued that the likeness argument fails in the case of alcoholism, Pickering states one possible response to this failure on the part of psychiatry as the concession that the classification [End Page 261] of alcoholism as an illness is "very much a matter of opinion (2003, p. 250). Because he then argues that the argument fails for logically analogous reasons in the case of schizophrenia, we may feel invited to draw the same conclusion about that condition. He later admits there is "some truth in the charge" that "the rejection of the likeness argument seems to introduce an unacceptable element of contingency into the way important questions about the categorization of schizophrenia and alcoholism are answered" (p. 253). His response to this is that it is not his arguments that lead to this element of contingency, and he reiterates that the likeness argument cannot get beyond such contingencies (p. 253).Certainly he seems committed to the view that no observational premises can "decide, or help decide, the issue" because the "detectable and observable features" of a purported mental illness "do not determine what description should be given of them" (p. 250). Even the fact that a particular description seems intuitively irresistible or "natural" cannot decide this. His argument on this point concerns the fact that what appears natural or intuitively obvious to us is... (shrink)

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical (...) import, is currently the preoccupation of some of the most influential and insightful contributors to the on‐going evidence‐based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life. (shrink)

Despite its potential hazards, the activity of questioning theoretical frameworks and and proposing solutions is necessary if progress is even to be possible. Intellectual history has by no means ended so we cannot expect to have all the answers, and from time to time the activity of critical questioning will be frustrating. But intellectual progress requires us to continue the process of asking fundamental questions. The alternative to thinking in this way is indeed unthinkable.

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, over-diagnosis, co- and multimorbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, health and social care, are being revised and (...) their relationships reconsidered: boundaries are indeed being redrawn; reasoning is being made 'fit for practice'. Ideas like 'person-centred care' are no longer phrases with potential to be helpful in some yet-to-be-clarified way: theorists and practitioners are working in collaboration to give them substantive import and application. (shrink)