While classifications of mental disorders have existed for over one hundred years, it still remains unspecified what terms such as 'mental disorder', 'disease' and 'illness' might actually denote. While ontologies have been called in aid to address this shortfall since the GALEN project of the early 1990s, most attempts thus far have sought to provide a formal description of the structure of some pre-existing terminology or classification, rather than of the corresponding structures and processes on the side of the (...) patient. We here present a view of mental disease that is based on ontological realism and which follows the principles embodied in Basic Formal Ontology and in the application of BFO in the Ontology of General Medical Science. We analyzed statements about what counts as a mental disease provided in the research agenda for the DSM-V, and in Pies' model. The results were used to assess whether the representational units of BFO and OGMS were adequate as foundations for a formal representation of the entities in reality that these statements attempt to describe. We then analyzed the representational units specific to mental disease and provided corresponding definitions. Our key contributions lie in the identification of confusions and conflations in the existing terminology of mental disease and in providing what we believe is a framework for the sort of clear and unambiguous reference to entities on the side of the patient that is needed in order to avoid these confusions in the future. (shrink)

In this paper, I examine the transition from zymotic views of disease to germ views in Britain in the mid-1800s. I argue that neither realist nor anti-realist accounts of theory-change can account for this case, because both rely on a well-defined notion of theory, which, as the paper will show, is inapplicable in this instance. After outlining the zymotic theory of disease, I show that, even though it hardly had anything in common with the germ theory, it was (...) highly successful. However, despite this success, it is not possible to identify stable elements that were carried over to the germ theory; thus, realists cannot account for the shift from one to the other. Anti-realists, however, don’t do much better: their focus tends to be on (radical) discontinuities across theories, yet the zymotic case does not exemplify this, either. Instead, there is a slow and complex evolution from zymotic to germ views, during which various zymotic elements are assimilated into the germ theory, until, eventually, none of the zymotic theory’s original elements are left. (shrink)

HARWOOD L and CLARK AM. Nursing Inquiry 2012; 19: 29–38Understanding health decisions using critical realism: home-dialysis decision-making during chronic kidney diseaseThis paper examines home-dialysis decision making in people with Chronic Kidney Disease (CKD) from the perspective of critical realism. CKD programmes focus on patient education for self-management to delay the progression of kidney disease and the preparation and support for renal replacement therapy e.g.) dialysis and transplantation. Home-dialysis has clear health, societal and economic benefits yet service (...) usage is low despite efforts to realign resources and educate individuals. Current research on the determinants of modality selection is superficial and insufficient to capture the complexities embedded in the process of dialysis modality selection. Predictors of home-dialysis selection and the effect of chronic kidney disease educational programmes provide a limited explanation of this experience. A re-conceptualization of the problem is required in order to fully understand this process. The epistemology and ontology of critical realism guides our knowledge and methodology particularly suited for examination of these complexities. This approach examines the deeper mechanisms and wider determinants associated with modality decision making, specifically who chooses home dialysis and under what circumstances. Until more is known regarding dialysis modality decision making service usage of home dialysis will remain low as interventions will be based on inadequate epistemology. (shrink)

The main purpose of this paper is to test structural realism against (one example from) the historical record. I begin by laying out an existing challenge to structural realism -- that of providing an example of a theory exhibiting successful structures that were abandoned -- and show that this challenge can be met by the miasma theory of disease. However, rather than concluding that this is an outright counterexample to structural realism, I use this case to (...) show why it is that structural realism, in its current form, has trouble dealing with theories outside physics. I end by making some concrete suggestions for structural realists to pursue if, indeed, they are serious about extending structural realism to other domains. (shrink)

The concept of disease has been the subject of a vast, vivid and versatile debate. Categories, such as "realist", "nominalist", "ontologist", "physiologist", "normativist" and "descriptivist", have been applied to classify disease concepts. These categories refer to underlying theoretical frameworks of the debate. The objective of this review is to analyze these frameworks. It is argued that the categories applied in the debate refer to profound philosophical issues, and that the complexity of the debate reflects the complexity of the (...) concept itself: disease is a complex concept, and does not easily lend itself to definition. (shrink)

The empirical evidence often justifies belief in scientific theories. For instance, the great wealth of chemical and other relevant data leaves us with no real alternative to believing that matter is made of atoms. Similarly, the natural history of past and present organisms makes it irrational to deny that life on earth has evolved from a common ancestry. Again, the character and epidemiology of infectious diseases effectively establishes that they are caused by microbes. Peter Lipton did much to illuminate the (...) logic of these and many similar inferences. Often the observed facts admit of only one good theoretical explanation. Rationality therefore dictates that we infer the truth of this explanation. (shrink)

It has recently been suggested that realist responses to historical cases featured in pessimistic meta-inductions are not as successful as previously thought. In response, selective realists have updated the basic divide et impera strategy specifically to take such cases into account and to argue that more modern realist accounts are immune to the historical challenge. Using a case study—that of the nineteenth-century zymotic theory of disease—I argue that these updated proposals fail and that even the most sophisticated recent realist (...) accounts remain vulnerable to the challenge from history. (shrink)

Mental and behavioral disorders represent a significant portion of the public health burden in all countries. The human cost of these disorders is immense, yet treatment options for sufferers are currently limited, with many patients failing to respond sufficiently to available interventions and drugs. High quality ontologies facilitate data aggregation and comparison across different disciplines, and may therefore speed up the translation of primary research into novel therapeutics. Realism-based ontologies describe entities in reality and the relationships between them in (...) such a way that – once formulated in a suitable formal language – the ontologies can be used for sophisticated automated reasoning applications. Reference ontologies can be applied across different contexts in which different, and often mutually incompatible, domain-specific vocabularies have traditionally been used. In this contribution we describe the Mental Functioning Ontology (MF) and Mental Disease Ontology (MD), two realism-based ontologies currently under development for the description of humanmental functioning and disease. We describe the structure and upper levels of the ontologies and preliminary application scenarios, and identify some open questions. (shrink)

In this paper, I consider what kind of normative work might be done by speaking of ecosystems utilising a 'medical' vocabulary – drawing, that is, on such notions as 'health', 'disease', and 'illness'. Some writers attracted to this mode of expression have been rather modest about what they think it might purchase. I wish to be bolder. Drawing on the idea of 'thick' evaluative concepts as discussed by McDowell, Williams and Taylor, and resorting to a phenomenological argument for a (...) kind of moral realism, I argue that the project of developing a robust understanding of the moral significance of recognising the health or illness of ecosystems is definitely a starter. (shrink)

The concept of disease has been the subject ofa vast, vivid and versatile debate. Categoriessuch as ``realist'', ``nominalist'', ``ontologist'',``physiologist'', ``normativist'' and``descriptivist'' have been applied to classifydisease concepts. These categories refer tounderlying theoretical frameworks of thedebate. The objective of this review is toanalyse these frameworks. It is argued that thecategories applied in the debate refer toprofound philosophical issues, and that thecomplexity of the debate reflects thecomplexity of the concept itself: disease is acomplex concept, and does not easily lenditself to (...) definition. (shrink)

In the traditional philosophical debate over different conceptual analyses of “disease,” it is often presupposed that “disease” is univocally definable and that there are clear boundaries which distinguish this univocal category “disease” from the category of “nondisease.” In this paper, I will argue for a shift in the discussion on the concept of “disease” and propose an alternative, pragmatic approach that is based on the conviction that “disease” is not a theoretical concept but a practical (...) term. I develop a view on which our use of the term “disease” is determined by two interacting factors, namely, value-laden considerations about the desirabilty of certain states and discoveries of cause which is/are explanatorily relevant. I show how these factors interact with regard to a taxonomy of kinds of diseases. This pragmatic approach will not lead me to a final definition of “disease,” but will result in a more realistic description of the way we build, use, apply, and change our concept of “disease.” Meanwhile, it is useful as a basis for critical reflection on disease-labeling in medicine. (shrink)

Newborn screening for the genetic disease phenylketonuria (PKU) is generally considered the greatest success story of applied human genetics. Even those generally skeptical of the value of genetic testing often comment enthusiastically on this program. In fact, PKU screening has been plagued with serious problems since its inception in the early 1960s. This essay describes some of these difficulties and asks what lessons they hold for other screening programs. It also argues that realism in our assessment of such (...) programs requires that we pay greater attention to the concrete experience of families. How screening should work in theory is of less importance than how it does work in practice. (shrink)

Disease-specific stem cell therapies, created from induced pluripotent stem cell lines containing the genetic defects responsible for a particular disease, have the potential to revolutionize the treatment of refractory chronic diseases. Given their capacity to differentiate into any human cell type, these cell lines might be reprogrammed to correct a disease-causing genetic defect in any tissue or organ, in addition to offering a more clinically realistic model for testing new drugs and studying disease mechanisms. Clinical translation (...) of these therapies provides an opportunity to design a more systematic, accessible and patient-influenced model for the delivery of medically innovative treatments to chronically ill patients. (shrink)

The biopsychosocial (BPS) model has been of considerable utility to those researching health and illness. This has been particularly the case for critical realists and those with a systemic orientation to their work. Whilst the strengths of the model are conceded in this article, its limitations are also examined. These relate to its ontological sophistication being compromised by its proneness to epistemological naivety. It is a model to explain the emergence of disease and disability, not a reflexive theory applicable (...) to the whole field of health research. This tension is linked to the emergence of a re-orientation of medical knowledge away from bio-medical reductionism. From the outset the model was not about a general critique, or a grand theory, of health and illness. Instead it was a useful intervention, on the part of medical practitioners, like George Engel and Adolf Meyer, to create a reformed medical model on behalf of their profession. Case studies of the problematics of diagnosis and medicalization are offered to illuminate the limitations of the BPS model for health researchers. (shrink)

I argue that neither realist nor anti-realist accounts of theory-change can account for the transition from zymotic views of disease to germ views. The trouble with realism is its focus on stable and continuous elements that get retained in the transition from one theory to the next; the trouble with anti-realism is its focus on the radical discontinuity between theories and their successors. I show that neither of these approaches works for the transition from zymes to germs: (...) there is neither continuity nor discontinuity, but, instead, a gradual evolution from zyme to germ views, during which germ elements are slowly incorporated into zymotic views until, eventually, none of the original zymotic constituents are left. I argue that the problem with both realism and anti-realism is that they rest on the unwarranted assumption that there are clearly delineated zymotic and germ theories as well as arguments for and against these theories, an assumption that does not hold. (shrink)

In the late 1720s and early 1730s, Christian Wolff writes a series of short treatises on general medical concepts such as health, disease, cause of disease, symptom, etc. The paper makes the claim that these texts should be considered as a pioneering attempt at developing a systematic philosophy of medicine based on metaphysical and epistemological investigations on medical concepts, doctrines, and practices. The main focus is on Wolff’s analysis of the concepts of health and disease in functional (...) terms and its connection to his teleological characterization of both natural and artificial machines. This also explains Wolff’s use of the normatively loaded concepts of fitness and nature to clarify the distinction between health as good functioning and disease as dysfunction. The conclusion is that Wolff’s mechanist view of living bodies and his realism about biological functions are just one side of the coin; the other is his commitment to a normative view of the human body’s nature and purposes. (shrink)

Since the September 11 attacks, a new security agenda has swept aside much of the old sensitivity and apathy about intervening in “failing” states. The war on terror has redefined “governance” from concentrating on issues of economic viability and popular rights to a focus on the capacity of states to generate sufficient “order” to deter or capture the agents of the new transnational security threats: terrorists, smugglers, money launderers, the carriers of zoonotic disease. As part of this process, the (...) governance standards of other states became part of Western states' own security agendas, generating new, self-interested incentives for aid and intervention. In this article, I explore the possibilities for developing a realist-informed normative framework for humanitarian intervention in the context of the post–September 11international concern with transnational threats. (shrink)

Alzheimer's disease, a form of senile dementia, is characterised by two kinds of pathological deposits in the brain, called plaques and tangles. The molecular nature of the deposits has been identified but there is as yet little understanding of the underlying biochemistry and cell biology that lead to their formation. Progress in this area would be greatly aided by a realistic animal model. Two recent papers describe the production of transgenic mice that develop significant aspects of Alzheimer‐like pathology. The (...) mice produced by Games et al.(1) develop plaques while those produced by Götz et al.(2) display the early stages of tangle pathology. (shrink)

The classification of ageing as a disease is fundamental to developing new pharmacological strategies that can target said phenomenon. The European Medicines Agency does not do this and maintains a questionable perspective based on the traditional naturalistic argument and the value-free ideal. An alternative is proposed which, inspired by consequentialism, is committed to considering ageing as a disease in European regulatory contexts as long as the ethical consequences are desirable. Within a realistic framework, I show that making this (...) decision would have moderate positive effects such as increased knowledge about antiageing pharmacology or potential greater chances of completing vital projects. Furthermore, we will see that the main arguments used by critics to show that the negative effects outweigh the positive ones are not sound. Therefore, I conclude that it would be beneficial for the European Medicines Agency to change its position on ageing. (shrink)

Learning and development are often linked in the organization studies literature. To understand the dynamics of organizational moral development, this paper utilizes the notion of organizational moral learning (OML). It is explored using three perspectives: organizational learning, Islamic and critical realist perspectives. The perspectives are then synthesized together to form a single framework, called the OML by ‘spiritual hearts’ framework. At the centre of the framework is the spiritual heart, the seat of profound understanding and moral consciousness. The heart plays (...) a central role in organizational moral development, especially with regard to its potential to be ‘purified’ and corrupted. Two extreme parameters then are created: on one side is the ‘purified hearts’ with high moral consciousness contributing towards OML, and on the other is the ‘corrupted hearts’ with high immoral consciousness contributing towards organizational immoral learning. Between the two extremes are the ‘diseased hearts’, possessing a mixture of moral and immoral consciousness to various degrees, and have the potentials to contribute to both moral and immoral developments. The paper further suggests strategies to facilitate OML and simultaneously inhibits organizational immoral learning. (shrink)

"Partial realism" is a common position in the contemporary philosophy of science literature. It states that the "essential" elements of empirically successful scientific theories accurately represent corresponding features the world. This thesis makes several novel contributions related to this position. Firstly, it offers a new definition of the concept of “empirical success”, representing a principled merger between the use-novelty and unification accounts. Secondly, it provides a comparative critical analysis of various accounts of which elements are "essential" to the success (...) of a theory, including structural realism and the divide et impera strategy. A novel account of essentialness, entitled the “empirically successful sub-theory "account", is defended. Thirdly, it is argued that the realism/anti-realism debate should put to the side metaphysical questions and focus instead on partial realism's commitment to the continuity of science. Because this commitment lacks metaphysical implications, it is referred to as "deflationary realism". Anti-realists cannot reject deflationary realism as a matter of a priori principle; its overall viability can therefore only be assessed by a careful examination of the history of science. Finally, another consequence of partial realism, named "partial rationalism", is defended. Partial rationalism states that, in cases where several competing theories have been suggested, scientists are rational just in case they accept the essential elements of each of the scientific theories on offer. This novel position subverts the existing literature on scientific "revolutions", as it sometimes demands that scientists devise a synthesis between competing scientific theories, instead of "choosing" only one. The philosophical points defended in this thesis are illustrated and supported by case studies from the history of science, including Fresnel’s wave theory of light, the Copernican revolution, the "neo-Darwinian synthesis" in evolutionary biology, the "prion revolution" in molecular biology, the miasma theory of disease, and the chemical revolution. (shrink)

Ecosystem health, as James Nelson argues, must be understood as having both descriptive and normative content; it is in this sense a 'morally thick' concept. The health analogy refers (a) at the similarities between conservation ecology and medicine or plant pathology as normative sciences, and (b) to the ability of ecosystems to 'heal' themselves in the face of disturbances. Nelson, however, goes beyond these two aspects and argues that judgements of illness in ecosystems only support moral obligations to protect them (...) if they are attributed a 'good of their own'. But this latter extension of the analogy flies in the face of ecological science, which has been forced to abandon organicism. If one separates the question of the warranted assertibility of environmentalists' goals from the question of where values in nature are located, the search for an objective realm of value realism can be seen to be unnecessary. (shrink)

Physical activity can prevent and treat multiple diseases. Exercise referral schemes have been used extensively as one healthcare pathway. Schemes typically involve the referral of an inactive individual, with a long term condition, for a time limited exercise programme. Evidence has shown limited benefit, yet the exploration of implementation is under researched. National guidance, in the United Kingdom, recommends that exercise referral schemes should not be commissioned unless behaviour change practices are implemented. Nonetheless, novel evaluations, which are sensitive to the (...) complex nature of behaviour change implementation, have not been undertaken. Therefore, this research sought to answer how, why, and in which circumstances behaviour change practices are implemented by exercise referral practitioners. Realist evaluation, a form of theory driven evaluation, was adopted to address the research question. Programme theory, the envisaged causal workings of implementation, was developed and tested to advance knowledge on how behaviour change practice can be achieved by exercise referral practitioners. An 8-month focused ethnography was used to develop programme theory. Subsequently, a survey was validated to empirically test programme theory. Adjudication between theory required an assessment of the fidelity to behaviour change practices. Therefore, vignettes were created and validated, which acted as a proxy to observations. The survey was then completed through online, and facilitated interviews, using a ‘think aloud’ methodology. The analysis showed that practice frameworks augment motivation when there is congruent practitioner characteristics and practice monitoring is utilised, whereas frameworks improve capability when faced with challenging attendees. Supportive leadership improves motivation when there is an organisational commitment to behaviour change and practitioners are passionate to empower attendees. Supportive leadership improves capability for implementation when a learning climate is created. Partnerships with medical professionals enhance implementation, through changes to motivation, when medical professionals commit and recognise the value of schemes, and partnerships enhance capability where medical professionals reinforce practice via congruent communication. On-going support enhances capability where practitioners are cognizant of their role and have lower behaviour change competencies, conversely, motivation is enhanced as practitioners become more capable. Exercise referral schemes risk being labelled ineffective without considering the implementation climate and fidelity to best practice guidance. This thesis provides portable and actionable findings, which could lead to a greater translation of behaviour change practices to applied settings in exercise referral and in other medically led community based self-management interventions. (shrink)

In recent years, philosophers have identified a number of moral and psychological harms associated with the attention economy (Alysworth & Castro, 2021; Castro & Pham, 2020; Williams, 2018). Missing from many of these accounts of the attention economy, however, is what exactly attention is. As a result of this neglect of the cognitive science of attention, many of these accounts are not empirically credible. They rely on oversimplified and unsophisticated accounts of not only attention, but self- control, and addiction as (...) well. Of note are accounts of the attention economy that rely on the ‘brain disease’ rhetoric of addiction and subsequent control failures (Aylsworth & Castro, 2021; Bhargava & Velasquez, 2021), accounts that rely on a strict dichotomy of top-down vs. bottom-up attention (Williams, 2018; Aylsworth & Castro, 2021), and accounts that construe attention as a limited resource (Williams, 2018). -/- Drawing on recent work from the neuroscience and psychology of attention, I demonstrate the shortcomings of these accounts and sketch a way forward for an empirically grounded account of the attention economy. These accounts tend to uphold strict dichotomies of voluntary control (e.g., compulsion versus choice, dual-process models of self-control, and top-down versus bottom-up) that cannot account for the complexities of attentional control, mental agency, and decision-making. As such, these empirically and conceptually impoverished accounts cannot adequately address the current so-called crisis of attention. To better understand the harms associated with the attention economy, we need an empirically responsible account of the nature and function of attention and mental agency. (shrink)

Our philosophical understanding of mental illness is being shaped by neuroscience. However, it has the paradoxical effect of igniting two radically opposed groups of philosophical views. On one side, skepticism and denialism assume that, lacking clear biological mechanisms and etiologies for most mental illnesses, we should infer they are constructions best explained by means of social factors. This is strongly associated with medical nihilism: it considers psychiatry more harmful than benign. On the other side of the divide, naturalism and reductionism (...) are on the look for failures in the biological functioning of the organism whenever a genuine mental illness occurs. Psychiatry as currently practiced, accordingly, exhibits the gaps of an ongoing research programme; a yet to be completed neuroscience would link mental illnesses with identifiable biological mechanisms. Both sides of this divide claim to be fostered by scientific discoveries and advances in neuroscience, when taken at face value. Against this background, we argue instead for a modest view. To that end, we draw attention to some nuances in the scientific realism debate. While contending that neuroscientific theories and models aim to provide true representations of their target systems, and can justifiably claim to have attained some, we argue that our confidence should not be placed beforehand in specific features of these scientific representations. Hence, it would be unwarranted to extract morals for psychiatry from posits (or their absence) in neuroscientific explanations of mental illnesses. To illustrate our position, we examine some recent discoveries in neuroscience concerning bipolar disorder. We conclude by linking our topic to a broader issue in the philosophy of medicine: insofar as psychiatry is a biomedical specialty, its classifications of health and disease are guided by pragmatic concerns, as well as by scientific discoveries. (shrink)

Ludwik Fleck’s Genesis and Development of a Scientific Fact is an extended argument for the inclusion of social factors in the history and philosophy of science. Fleck uses the history of syphilis as his case study, which falls into two parts. In the first two chapters of his book, Fleck presents a history of the change of the concept of syphilis as a “carnal scourge with strong moralistic connotations” in the middle ages to the modern concept of syphilis as an (...) infectious disease (1979, 77). In the second part of the book, he presents a detailed account of the development of a serum test for syphilis, the Wasserman reaction. Fleck also argues that perception is theory-laden, for example, in his comparative study of anatomical drawings, and for the importance of social pressures on the development of science, for example, in his discussion of the rivalry between nations to first develop a cure for syphilis, as demanded by politicians (1979, 133 ff. and 68). (shrink)

It is a popular view thatpractical deliberation excludes foreknowledge of one's choice. Wolfgang Spohn and Isaac Levi have argued that not even a purely probabilistic self-predictionis available to thedeliberator, if one takes subjective probabilities to be conceptually linked to betting rates. It makes no sense to have a betting rate for an option, for one's willingness to bet on the option depends on the net gain from the bet, in combination with the option's antecedent utility, rather than on the offered (...) odds. And even apart from this consideration, assigning probabilities to the options among which one is choosing is futile since such probabilities could be of no possible use in choice. The paper subjects these arguments to critical examination and suggests that, appearances notwithstanding, practical deliberation need not crowd outself-prediction. (shrink)