Rani Lill Anjum

At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.

Causation and evidence-based practice: an ontological review.

This paper explores the nature of causation within the framework of evidence-based practice (EBP) for health care. The aims of the paper were first to define and evaluate how causation is presently accounted for in EBP; second, to present an alternative causal account by which health care can develop in both its clinical application and its scientific research activity. The paper was premised on the idea that causation underlies medical and health care practices and impacts on the way we understand health science research and daily clinical practice. The question of what causation is should therefore be of utmost relevance for all concerned with the science, philosophy and progress of EBP. We propose that the way causation is thought of in contemporaneous health care is exposed by evidential frameworks, which categorize research methods on their epistemological strengths. It is then suggested that the current account of causation is limited in respect of both the functionality of EBP, and its inherent scientific processes. An alternative ontology of causation is provided, which has its roots in dispositionalism. Here, causes are not seen as regular events necessitating an effect, but rather phenomena that are highly complex, context-sensitive and that tend towards an effect. We see this as a better account of causation for evidence-based health care.

Effects of context

Complexity should be at the heart of any viable theory of causation. Without it, we cannot give a sensible account of the importance of context. With many causal factors in play, jointly producing an effect, we come to understand the context-sensitive nature of causation. Cases of hypersensitivity, unintended consequences and antipathetic reactions will be outlined together with some considerations for our interventions.

The Tendential Theory of Sporting Prowess

The results of sport would not interest us if either they were necessitated or they were a matter of pure chance. And if either case were true, the playing of sport would seem to make no sense either. This poses a dilemma. But there is something between these two options, namely the dispositional modality. Sporting prowess can be understood as a disposition towards victory and sporting liabilities a disposition towards defeat. The sporting contest then pits these net prowesses against each other. The stronger will tend to beat the weaker but no more than tend. This makes sense of the sporting contest in which the weaker knows they still can win. The stronger team can lose though they do not tend to do so. The dilemma is thus escaped.

Double prevention and powers

Abstract Does A cause B simply if A prevents what would have prevented B? Such a case is known as double prevention: where we have the prevention of a prevention. One theory of causation is that A causes B when B counterfactually depends on A and, as there is such a dependence, proponents of the view must rule that double prevention is causation. However, if double prevention is causation, it means that causation can be an extrinsic matter, that the cause and effect need not be connected by a continuous chain of events, that there can be causation by absence, and that there can be causation at a distance. All of these implications jar with strong intuitions we have about the nature of causation. There is, on the other hand, a theory of causation based on an ontology of real dispositions, where causation involves the passing around of powers. This theory in contrast entails that double prevention is not causation and, on this issue, it can claim a victory over the counterfactual dependence account.

A philosophical argument against evidence-based policy

RATIONALE, AIMS AND OBJECTIVES Evidence-based medicine has two components. The methodological or ontological component consists of randomized controlled trials and their systematic review. This makes use of a difference-making conception of cause. But there is also a policy component that makes a recommendation for uniform intervention, based on the evidence from randomized controlled trials. METHODS The policy side of evidence-based medicine is basically a form of rule utilitarianism. But it is then subject to an objection from Smart that rule utilitarianism inevitably collapses. If one assumes (1) you should recommend the intervention that has brought most benefit (the core of evidence-based policy making), (2) individual variation (acknowledged by use of randomization) and (3) no intervention benefits all (contingent but true), then the objection can be brought to bear. CONCLUSIONS A utility maximizer should always ignore the rule in an individual case where greater benefit can be secured through doing so. In the medical case, this would mean that a clinician who knows that a patient would not benefit from the recommended intervention has good reason to ignore the recommendation. This is indeed the feeling of many clinicians who would like to offer other interventions but for an aversion to breaking clinical guidelines.

What is the guidelines challenge? The CauseHealth perspective

This paper is an introduction to the conference, The Guidelines Challenge, held in Oxford in October 2017. My aim is to explain our motivation for organising this conference, as part of the research project Causation, Complexity, and Evidence in Health Sciences (CauseHealth). Depending on the professional starting point, the guidelines challenge can be interpreted in a number of ways. Our idea with this conference was to discuss guidelines from 3 overarching perspectives: practice, policy, and philosophy. In particular, we wanted to discuss some of the challenges that face anyone developing and implementing clinical guidelines in the evidence-based era of medicine. This introduction gives a brief overview of what CauseHealth sees as the guidelines challenge from these perspectives. More attention is given to the philosophical issues with which the CauseHealth project is particularly concerned, although a proper treatment or discussion of these issues naturally falls outside the scope of this introduction.

Causation in evidence‐based medicine: in reply to Strand and Parkkinen

Strand and Parkkinen criticize our dispositional account of causation in evidence-based medicine for failing to provide a proper epistemology of causal knowledge. In particular, they claim that we do not explain how causal inferences should be drawn. In response, we point out that dispositionalism does indeed have an account of the epistemology of causation, including counterfactual dependence, intervention, prediction and clinical decision. Furthermore, we argue that this is an epistemology that fits better with the known fallibility of even our best-informed predictions. Predictions are made on the basis that causes dispose or tend towards their effects, rather than guarantee them. The ontology of causation remains a valuable study for, among other reasons, it tells us that powers do not always combine additively. This counts against the monocausality that is tested by randomized controlled trials.

Fundamentals of causality

The orthodox view of the fundamentals of causality can be traced back to the empiricist philosophy of David Hume. Hume said that for causality to occur, the cause and effect must be spatially together, the cause must occur before the effect and must always be followed by that type of effect. Hume also thought that our concept of cause included necessity, but he rejected this as unjustified by the evidence of our sense. We show how all four of these conceptual assumptions about what it is for one this to cause another can be challenged. An alternative view based on real powers or dispositions can allow causation without necessity, constant conjunction, temporal priority, or even contiguity.

Powers and Potentiality

Analytic philosophers have in recent decades rediscovered powers as the basis for an all-encompassing metaphysics and philosophy of nature. What recommends the powers view is its explanatory utility, including a putative explanation of potentiality. Powers can be understood as the elements in the world that provide the grounding for potentiality in actuality. They can be productive of their manifestations but typically do so only in certain circumstances. This will explain why there can be some potentialities that are not actualised and also why there are some constraints on what can be. The powers account also makes potentialities a possible subject of scientific investigation as powers are to a degree empirically accessible. It is important, however, that we provide a plausible account of how powers are able to bring things about: how they able to make some of the potentialities actualities. A mutual manifestation model is preferred to the stimulus-response model of production. It was C. B. Martin who introduced the mutual manifestation model but it is argued that his account needs to be amended so that it resembles less mereological composition and more causation.