Breathless in Bristol (1)

PhD student on the Life of Breath project Tina Williams, writes about the recent Philosophy of Medicine conference, with help from Emily Chester and Charlotte Withers:

Cutting-edge studies in the diverse field of Philosophy of Medicine were presented before delegates from the medical, psychiatric, philosophical and inter-disciplinary fields. This post gives an overview of the first day of this event (day two to be covered in a further post), attending to interesting elements drawn from the talks, including their context in the field of philosophy of medicine (unfortunately it would be impossible to give whole reviews here, but please keep an eye out for the forthcoming publication of the papers presented here).

This first day started with an excellent keynote by Rachel Cooper from Lancaster University (‘Where’s the problem?’), probing the standard model of disorder, in which a disorder is located ‘within’ an individual person. Subsequently, that individual is presumed to have a sense of ownership of their disorder. This paper offered an alternative stance: perhaps some disorders are located externally, that is, they cannot be relegated as simply arising from the individual. The key example given by Cooper can be found in Sanity, Madness and the Family (1964), by R. D. Laing and A. Esterton, who argued that what was registered as madness or disorder in individuals was actually explainable when their family backgrounds and interactions were observed. Therefore, a woman who may appear, when observed alone, as a paranoid schizophrenic, would not seem so when observed alongside her family who had fostered an environment in which the ‘disordered’ woman was led to believe that her so-called paranoias were true.

Cooper suggested that the externalisation of disorder links to the ever-expanding concept of extended cognition. In particular, she linked this to Clark and Chalmers’s influential 1988 paper ‘The Extended Mind’, which claimed that a lot of thinking goes on in the world rather than in individuals. The concluding section addressed weaknesses in the above examples, leading to the resounding question of what determines a fair environment for the testing of individuals when deciding where a disorder is located.

The next three papers were by Elselijn Kingma (‘Metaphysics of pregnancy’), Georg Repnikov (‘Remodeling the structure of psychopathology in search of causal mechanism’) and Kirstin Borgerson (‘Towards an epistemic justification for research – practice integration in medicine’). Kingma critiqued Smith and Brogaerd’s (2003) argument that the ‘embryo’s location inside the maternal womb poses no problem for trans-temporal identity’, and thus was differentiated from the mother by being ‘inside her’ as a distinct entity, rather than as part of her (Kingma, 2015). Instead she argued that the foetus is part of the ‘maternal organism’ until birth, by virtue of the connection of foetus and mother via the umbilical cord, placenta, and other topological connections, using Smith and Brogaerd’s own criterion of topological connectedness and presentation of what an organism is. Ultimately, she suggested, rejecting a substance-view of the human organism may be preferable, but still leaves the problems of when the organism comes into existence (at 16 weeks gestation? At birth?); and that human organisms appear to be very different to what we usually conceive of by virtue of the suspicion that they can be part of one another (in pregnancy) rather than discrete beings.

Repnikov discussed how the DSM approach to classification has serious ramifications in psychiatry that contribute, if not directly cause, the current lack of progress in psychiatric research that has led to researchers seeking solutions via ‘data-driven development of a structurally valid classification through latent variable modelling’. He critiqued this, suggesting that we should consider idiographic causal network approaches. Such approaches would identify homogenous groups of patients fruitful for this research agenda.

Next, Kirsten Borgerson began by noting the accepted distinction between medical research and medical practice that has given rise to separate ethical frameworks, and the establishment of new concepts to address conflicting issues between the two fields. Arguing that characteristic activities that most ‘resemble’ medical practice are more conducive to producing high-quality medical knowledge, she suggested that utilising patients ‘into ongoing knowledge productive activities’ in both research and practice will likely achieve more efficacious treatment outcomes for patients. This certainly resonated with some of the members of the Life of Breath Project: one of our aims is both to give a voice to the patients (particularly using phenomenology to describe first person accounts), to further knowledge of symptoms of breathlessness, and to contribute to patients’ and clinicians’ understanding of the lived experience of disorders with respiratory distress, and hopefully improve treatment outcomes. The bridging of medical practice and research would be undoubtedly advantageous, and certainly we can see application in our areas of research.

After lunch, Sean Valles gave a paper on ‘Values and Epistemic Risks in the Debate Over Race Concepts’ Roles in Medicine’, presenting the current debate on the use and roles of race concepts within medicine, such as how the use of race concepts can lead to the production and proliferation of inaccurate stereotypes regarding biological racial differences within medical research. Practice too can be affected: for example, the under-prescription of appropriate pain killers to African American patients in comparison with the (perhaps over-) prescription to Caucasian patients. His paper further explored the risks and benefits in both cases: using and not using race concepts. We have seen one potential (and realized) risk; but then perhaps the role of race would help rectify the imbalance of target population’s through attendance to ‘minority populations’. Valles also examined values and epistemic rules in research, imprecise variables, and the mismatch in genetics between racial categories and supposed genetic differences showing problems with the concept of ‘race’ (imprecise). He concluded that disputes do not seem to turn on the issue of medicine’s use of race, but rather ‘precision as an epistemic value’ (Valles, 2015).

Adam La Caze examined the problems tied to drug safety in ‘Improving the assessment and communication of drug safety’. Rather than seeing the problem in terms of inappropriate or lack of appropriate methodology when assessing the safety of drugs, he argued that how the evidence gathered on their safety is ‘amalgamated and communicated’ results in an ‘unmet challenge’. Why? Using the example of clopidogrel-proton pump inhibitor interaction, he shows that regulatory bodies not only provide advice at once both conflicting and incomplete (hence highlighting an issue with the amalgamation of evidence); the EBM – heuristic (hierarchal structuring of methods according to evidence result in ‘better’ evidence to utilise when making decisions on therapy choice) is ‘mis-applied’. His paper suggests that work by Nancy Cartwright (2011) on argument over method may help redress these, and that a causal approach to drug safety amalgamation as given by the epistemic causal theory by Russo and Williamson (2007) can start this process.

Sarah Wieten‘s paper ‘Consensus Conferences as GOBSAT  (Good ole boys sit around a table) Medicine: the (non?) problems of exclusion, rationalism and equipoise for EBM’ looked at the low role accorded by EBM to medical consensus conferences in the hierarchy of evidence. She highlighted how EBM itself is guilty of the criticisms that it accords to consensus conference evidence; selection bias (thus social exclusion) and a heavy reliance on ‘rationalism’, to name but two. She also looked at the positive role social inclusion plays in consensus conferences, thereby avoiding any charges of exclusivity of the ‘good ole boys’. This doesn’t save consensus conferences, however. She notes the lack of ‘equipoise’ that would give a better argument against consensus conferences than EBM’s reliance on exclusivity or rationalism. In short, EBM would have a stronger criticism against GOBSAT if it utilized this issue, rather than it’s hypocritical focus on exclusion and rationalism.

The final session of the day started with Benjamin H. Chin-Yee: ‘Re-evaluating concepts of biological function in clinical medicine: towards a new naturalistic theory of disease’. This paper began with discussing adequate disease theory desiderata: descriptive, normative, meeting objective epistemic standards, and naturalistic. For instance, Boorse and Wakefields’ accounts of disease that both appeal to the concept of function (and thus dysfunction) within their explanations. However, Chin-Yee notes that the concept of function within the discipline of philosophy of biology is not fully acceptable, nor clear. Different theories appear to give the notion of ‘function’ differing meanings, quite apart from the worry of attributing ‘function’ to biological entities. Moreover, these accounts fail to meet the standard of accurate disease theory desiderata through appeals to either evolutionary function or ahistorical function (perhaps mediated by individual fitness). Through a revaluation of medicines usage of the concept of ‘biological function’ in conjunction with the incorporation of normative import and descriptive accuracy, he presented a naturalistic dysfunction theory that meets the required standards without abandoning such a pursuit in favour of some other account of disease, and gave clinical examples to demonstrate this.

Marianne Boenink presented a paper on biomarkers, which neither over- nor down-played their potential significance in reconciling the traditional dichotomy between disease and illness. ‘Signs of the time: Biomarkers and the relation between disease and illness’ examined the benefits of research into biomarkers accorded by contemporary biomedical research and it’s relationship to so-called personalised medicine. Carefully considering the oft-quoted worry that biomarkers’ use in personalised medicine is actually about treatment shaped by bodily characteristics (and thus a typical biomedical reductive approach disguised as person-centred, thereby sneakily meeting the requirement), she instead argues convincingly that ‘biomarker measurements may help to narrow the gap between disease and illness after all’ (2015). This is through: 1. how biomarker research presents disease as process orientated, thus bringing back the role of time in disease (which is part of presentations of illness, but usually left out of disease theories) and 2. the fact that biomarkers are ‘tailored’ to individuals and what is normal for them rather than some heterogeneous reference group. Finally, to make sense of biomarker measurements, she suggests that they must be located within the context of the both relevant population research and subjective experiences. This means that utilising such an approach would allow for both the (standardly required) objective disease observations to be considered alongside subjective illness experiences so as to produce knowledge and understanding of the disease via a fruitful dialogic relationship in medicine.

The final talk of the day was by Stephen John, who presented an earlier version of his paper ‘Cancer screening, risk communication and the reference class problem’ at one of our philosophy of medicine seminars earlier in 2015. He began by discussing the claim made by philosophers that individual risk of a particular disease must be made against a reference class to be both coherent and meaningful (cancer being a case in point). Of course, what qualifies as the correct type of reference class (broad or narrow?) causes debate! John points out that a broader (rather than the narrowest) reference class may be appropriate in the context of risk communication (due to the ‘prevention paradox’). However, he argues that even in such a case there still appears to be something wrong in favouring a broader class in this way. His suggested resolution to such a problem turns on the semantics of risk claims, but then moved on to make a very pertinent point, both in the context of his paper and to our conference call overall:

I suggest that this case implies a problem for the premise underlying the call for papers for this workshop: that one can discuss the philosophy of medicine without discussing medical ethics. Rather, in a world of risk factor epidemiology, it may be impossible to solve various apparently theoretical problems without thinking through some (very broadly) ethical issues (John, 2015).

As we left for the conference dinner, this was food for thought indeed.